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The authors announce the creation of a new feature and the call for papers to be included in a future issue of the periodical. The initial theme selected entails the improvement of efficiency and value in health care which is set to improve the quality of American Healthcare System. This theme issue is supported by the Agency for Healthcare Research and Quality (AHRQ).

An introduction to various articles within the issue which focus on incentives for physicians is presented.

Policy makers (both public and private) are seeking ways to improve the value delivered within our health care system, that is, using fewer resources to provide the same benefit to patients, or using equivalent resources to provide more benefit. One strategy is to alter the predominant fee-for-service (FFS) economic incentives in the current system. To inform such policy changes, this paper identifies areas in which little is known about the effects of specific incentives (FFS, salary, etc.) on the two components of value: resource use and quality. Specific suggestions are offered regarding research that would be informative for policy makers, focusing on fundamental "building block" studies rather than overall evaluations of complex interventions, such as accountable care organizations. This research would better identify critical aspects of the FFS model and salary-based payments that are particularly problematic, as well as situations in which FFS or salary may be less problematic. The research would also explore when alternatives, such as episode-based payment might be feasible, or simply be hypothetical solutions. The availability of electronic health record-based data in various delivery systems would allow many of these studies to be accomplished in 3-5 years with budgets manageable by public and private funding sources. [ABSTRACT FROM AUTHOR]

An introduction to various papers within the issue which provide an overview of the current state of the research literature around improving the value of the health care system in the U.S. such as payment incentives and the theory and practice of fee-for-service is presented.

The article presents author's comments on the Health Services Research exploiting the membership on a committee that advises Medicare on administered pricing system for physician services in Medicare Part B. It mentions that the traditional fee-for-service Medicare program depends on administered prices. It focuses on the Specialty Society Relative Value Scale Update Committee (RUC) and the U.S. Centers for Medicare & Medicaid Services (CMS).

This paper presents longitudinal data representing federal funding for health services research and discusses the observed trends in the larger context of overall funding for research and development in the United States. By putting into context public and private funding trends, the authors examine how these trends effect the supply and demand of the health services research workforce. [ABSTRACT FROM AUTHOR]

Objectives: To explore (1) differences in validity and feasibility ratings for geriatric surgical standards across a diverse stakeholder group (surgeons vs. nonsurgeons, health care providers vs. nonproviders, including patient-family, advocacy, and regulatory agencies); (2) whether three multidisciplinary discussion subgroups would reach similar conclusions.Data Source/study Setting: Primary data (ratings) were reported from 58 stakeholder organizations.Study Design: An adaptation of the RAND-UCLA Appropriateness Methodology (RAM) process was conducted in May 2016.Data Collection/extraction Methods: Stakeholders self-administered ratings on paper, returned via mail (Round 1) and in-person (Round 2).Principal Findings: In Round 1, surgeons rated standards more critically (91.2 percent valid; 64.9 percent feasible) than nonsurgeons (100 percent valid; 87.0 percent feasible) but increased ratings in Round 2 (98.7 percent valid; 90.6 percent feasible), aligning with nonsurgeons (99.7 percent valid; 96.1 percent feasible). Three parallel subgroups rated validity at 96.8 percent (group 1), 100 percent (group 2), and 97.4 percent (group 3). Feasibility ratings were 76.9 percent (group 1), 96.1 percent (group 2), and 92.2 percent (group 3).Conclusions: There are differences in validity and feasibility ratings by health professions, with surgeons rating standards more critically than nonsurgeons. However, three separate discussion subgroups rated a high proportion (96-100 percent) of standards as valid, indicating the RAM can be successfully applied to a large stakeholder group. [ABSTRACT FROM AUTHOR]

Objectives: To examine: (1) what elements of patient-centered medical homes (PCMHs) are typically provided to low-income populations, (2) whether PCMHs improve health behaviors, experiences, and outcomes for low-income groups.Data Sources/study Setting: Existing literature on PCMH utilization among health care organizations serving low-income populations.Study Design: Systematic review and meta-analysis.Data Collection/extraction Methods: We obtained papers through existing systematic and literature reviews and via PubMed, Web of Science, and the TRIP databases, which examined PCMHs serving low-income populations. A total of 434 studies were reviewed. Thirty-three articles met eligibility criteria.Principal Findings: Patient-centered medical home interventions usually were composed of five of the six recommended components. Overall positive effect of PCMH interventions was d = 0.247 (range -0.965 to 1.42). PCMH patients had better clinical outcomes (d = 0.395), higher adherence (0.392), and lower utilization of emergency rooms (d = -0.248), but there were apparent limitations in study quality.Conclusions: Evidence shows that the PCMH model can increase health outcomes among low-income populations. However, limitations to quality include no assessment for confounding variables. Implications are discussed. [ABSTRACT FROM AUTHOR]

Objective. To assess the impact of the Children's Health Insurance Program (CHIP) on the distribution of health insurance coverage for low-income children. Data Source. The primary data for the study were from the 1997, 1999, and 2002 National Survey of America's Families (NSAF), which includes a total sample of 62,497 children across all 3 years, supplemented with data from other data sources. Study Design. The study uses quasi-experimental designs and tests the sensitivity of the results to using instrumental variable and difference-in-difference approaches. A detailed Medicaid and CHIP eligibility model was developed for this study. Balanced repeated replicate weights were used to account for the complex sample of the NSAF. Descriptive and multivariate analyses were conducted. Principle Findings. The results varied depending on the approach utilized but indicated that the CHIP program led to significant increases in public coverage (14–20 percentage points); and declines in employer-sponsored coverage (6–7 percentage points) and in uninsurance (7–12 percentage points). The estimated share of CHIP enrollment attributable to crowd-out ranged from 33 to 44 percent. Smaller crowd-out effects were found for Medicaid-eligible children. Conclusions. Implementation of the CHIP program resulted in large increases in public coverage with estimates of crowd-out consistent with initial projections made by the Congressional Budget Office. This paper demonstrates that public health insurance expansions can lead to substantial reductions in uninsurance without causing a large-scale erosion of employer coverage. [ABSTRACT FROM AUTHOR]

Objective. This paper reflects on the progress of the original Cash and Counseling states, and shows how this model has spread, how it has evolved over time, and what is left to improve. It then discusses the generalizability of the Cash and Counseling approach beyond long-term care and ventures some thoughts on what still needs to be learned. Finally, this paper suggests some of the contingencies that could affect the diffusion of this innovation. Data Sources/Study Setting. Drawing from ten years of experiences with the fifteen Cash and Counseling states, plus their analyses of current trends and future opportunities and threats, the framers of the Cash and Counseling model reflect on future directions. Study Design. This paper is essentially a policy-driven analysis of how the Cash and Counseling model has been sustained and disseminated, how it is likely to develop, and what still needs to be learned. Principal Findings. The basic Cash and Counseling model appears adaptable to different state environments and populations, but that hypothesis will be severely tested as more and more states seek to replicate. As one step to promote flexibility while capturing and preserving the essence of the model that led to such promising research results, the Cash & Counseling National Program Office developed a “Vision Statement”. Conclusions. The Cash and Counseling approach is not for everyone, but it is clearly a choice many participants desire. Its development merits monitoring. [ABSTRACT FROM AUTHOR]

Objective. This paper uses a unique database to examine premiums paid by beneficiaries for Medigap supplemental coverage. Average premiums charged by insurers are reported, as well as premiums by enrollee age and gender, and additional policy characteristics. Marginal prices for Medigap benefits are estimated using hedonic price regressions. In addition, the paper considers how additional policy characteristics and geographic differences in the use and cost of medical care affect premiums. Data Sources/Study Setting. A comprehensive database on premiums paid by beneficiaries for newly issued Medigap policies in the year 2000 along with state-level characteristics. Study Design. Hedonic pricing equations are used to estimate implicit prices for Medigap benefits. Data Collection/Extraction Methods. The Centers for Medicare & Medicaid Services contracted for the creation of a detailed database on Medigap premiums. Data were collected in three stages. First, letters were sent directly to insurers requesting premium data. Second, letters were directly to state insurance commissioner's offices requesting premium data. Last, each state insurance commissioner's office was visited to collect missing data. Principal Findings. With the exceptions of the part B deductible and drug benefit, Medigap supplemental insurance is priced consistent with the actuarial value of benefits offered under the standardized plans. Premiums vary substantially based on rating method, whether the policy is guaranteed issue, Medigap Select, or explicitly for smokers. Premiums increase with enrollee age, but do not vary between men and women. The relationship between premiums and enrollee age varies across rating methods. Attained-age policies show the strongest relationship between age and premiums, while community-rated premiums, by definition, do not vary with age. Medigap supplemental insurance premiums are higher in states with poorer health, greater utilization, and greater managed care penetration. Conclusions. Despite the high cost, Medigap plans are generally priced in accordance with the actuarial value of benefits. The primary exception is the drug benefit, which appears to be subject to substantial adverse selection. Benefits such as the part B deductible and at-home recovery benefit offer little value to consumers. Several states require insurers to community rate premiums. Such regulation has important implications for premiums, and research needs to consider the impact of such regulation on the Medigap market. [ABSTRACT FROM AUTHOR]

Health care clinicians successfully apply proven medical evidence in common acute, chronic, or preventive care processes less than 80 percent of the time. This low level of reliability at the basic process level means that health care's efforts to improve reliability start from a different baseline from most other industries, and therefore may require a different approach. This paper describes The Institute for Healthcare Improvement's (IHI) current approach to improving health care reliability, including a useful nomenclature for levels of reliability, and a focus on improving reliability of basic health care processes before moving on to more sophisticated high reliability organization concepts. Early IHI work with a community of health care reliability innovators has identified four themes in health care settings that help to explain at least a portion of the gap in process reliability between health care and other industries. These include extreme dependence on hard work and personal vigilance, a focus on mediocre benchmark outcomes rather than process, great tolerance of provider autonomy, and failure to create systems that are specifically designed to reach articulated reliability goals. This paper describes our recommendations for the initial steps health care organizations' might take, based on these four themes, as they begin to move toward higher reliability. [ABSTRACT FROM AUTHOR]

Objective. To measure the change in U.S. women and children's health insurance coverage as a result of welfare reform (i.e. the creation of Temporary Assistance for Needy Families or TANF) in 1996. Data Source. 1992–1999 longitudinal data from the Survey of Income and Program Participation (SIPP) merged with data on the timing of state implementation of welfare reform after 1996. Two key advantages of the SIPP data are that they permit matching type of insurance coverage to the welfare policy environment in each state in each month, and permit controlling for individual-level fixed effects. Study Design. We measure how much insurance coverage changed after welfare reform using a difference in differences method that eliminates the influence of time-invariant unobserved individual heterogeneity and of statewide trends in insurance coverage. Models also control for individual, state, and year fixed effects, individual-level characteristics such as education, age, and number of children, plus state-level variables such as real per capita income, real minimum wage, and Medicaid eligibility. Data Collection/Extraction Methods. We limit our analysis to the SIPP data specific to the month just completed prior to the interview; as a result, we have up to twelve observations for each individual in the SIPP. This paper uses pooled data from the 1992–1996 panels of the SIPP covering the period 1992–1999. Publicly available state identifiers permit the merger of state policies and macroeconomic variables with the SIPP. Principal Findings. TANF implementation is associated with an 8.1 percent increase in the probability that a welfare-eligible woman was uninsured. Welfare reform had less of an impact on the health insurance coverage of children. For example, TANF implementation was associated with a 3.0 percent increase in the probability that a welfare-eligible child lacked health insurance. Conclusions. An unintended consequence of welfare reform was to adversely impact the health insurance coverage of economically vulnerable women and children, and that this impact was several times larger than the previous literature implies. [ABSTRACT FROM AUTHOR]

This article focuses on quality improvement in medical care in the U.S. Efforts, particularly in the last decade or so that have been undertaken to improve the quality and efficiency of medical care. Changing the behavior of physicians and other health care workers is at the crux of many of these efforts. Clinical pathways and computerized decision support have been advocated to improve adherence with practice guidelines, and Quality Improvement Organizations have been charged with assisting providers in quality improvement activities. Clinical pathways, structured care plans that note the essential elements of care by hospital day, have been widely used by hospitals in efforts to improve the quality and efficiency of care.

Introduces a series of papers on consumer-driven health care in the U.S. Emergence of consumer-driven health plans; State of the health care industry; Consumer response to the plan; Advantages over other managed care plans.

Editorial. Elaborates on the definition of health services research (HSR) adopted by the U.S.-based Association for Health Services Research to reflect its evolution and sophistication. Suggestion that HSR is a multidisciplinary field of scientific investigation on how social factors, financing systems, organizational structures and processes health technologies affect access to health care.

An introduction is presented in which the editor discusses various reports within the issue on topics including the Massachusetts Health Reform Survey, self-reported health measures in predicting individuals with high future health care needs, and the American Community Survey and the Survey of Income Program Participation.

Objective The Patient Protection and Affordable Care Act ( ACA) increases Medicaid physician fees for preventive care up to Medicare rates for 2013 and 2014. The purpose of this paper was to model the relationship between Medicaid preventive care payment rates and the use of U.S. Preventive Services Task Force ( USPSTF)-recommended preventive care use among Medicaid enrollees. Data Sources/Study Session We used data from the 2003 and 2008 Medical Expenditure Panel Survey ( MEPS), a national probability sample of the U.S. civilian, noninstitutionalized population, linked to Kaiser state Medicaid benefits data, including the state Medicaid-to-Medicare physician fee ratio in 2003 and 2008. Study Design Probit models were used to estimate the probability that eligible individuals received one of five USPSF-recommended preventive services. A difference-in-difference model was used to separate out the effect of changes in the Medicaid payment rate and other factors. Data Collection/Extraction Methods Data were linked using state identifiers. Principal Findings Although Medicaid enrollees had a lower rate of use of the five preventive services in univariate analysis, neither Medicaid enrollment nor changes in Medicaid payment rates had statistically significant effects on meeting screening recommendations for the five screenings. The results were robust to a number of different sensitivity tests. Individual and state characteristics were significant. Conclusions Our results suggest that although temporary changes in primary care provider payments for preventive services for Medicaid enrollees may have other desirable effects, they are unlikely to substantially increase the use of these selected USPSTF-recommended preventive care services among Medicaid enrollees. [ABSTRACT FROM AUTHOR]

The United States is in the midst of a multifaceted public health crisis, marked by increasing midlife mortality rates among nearly all racial and ethnic groups.[[1]] The burden of this crisis has fallen most heavily among vulnerable populations, particularly individuals with lower levels of income and education.[[2]] Patterns of rising mortality - which vary across time, space, and causes of death - suggest a complex set of underlying causes, many of which may have been operative for decades.[2] How do the findings speak to the potential consequences of other trends in urban housing, in particular gentrification, whose relationship to evictions and health outcomes has thus far been shown to be mixed? America's declining well-being, health, and life expectancy: not just a white problem. 33 Fazel S, Geddes JR, Kushel M. The health of homeless people in high-income countries: descriptive epidemiology, health consequences, and clinical and policy recommendations. [Extracted from the article]

Objective To provide a tutorial for using propensity score methods with complex survey data. Data Sources Simulated data and the 2008 Medical Expenditure Panel Survey. Study Design Using simulation, we compared the following methods for estimating the treatment effect: a naïve estimate (ignoring both survey weights and propensity scores), survey weighting, propensity score methods (nearest neighbor matching, weighting, and subclassification), and propensity score methods in combination with survey weighting. Methods are compared in terms of bias and 95 percent confidence interval coverage. In Example 2, we used these methods to estimate the effect on health care spending of having a generalist versus a specialist as a usual source of care. Principal Findings In general, combining a propensity score method and survey weighting is necessary to achieve unbiased treatment effect estimates that are generalizable to the original survey target population. Conclusions Propensity score methods are an essential tool for addressing confounding in observational studies. Ignoring survey weights may lead to results that are not generalizable to the survey target population. This paper clarifies the appropriate inferences for different propensity score methods and suggests guidelines for selecting an appropriate propensity score method based on a researcher's goal. [ABSTRACT FROM AUTHOR]

Objective To describe data collection methods and to audit staff data entry of patient self-reported race/ethnicity/ancestry and preferred spoken language (R/E/A/L) information. Data Source/Study Setting Large mixed payer outpatient health care organization in Northern California, June 2009. Study Design Secondary analysis of an audit planned and executed by the Department of Clinical Services. Data Collection/Extraction Methods We analyzed concordance between patient written responses and staff data entry. Principal Findings The data entry accuracy rate across questions was high, ranging from 92 to 97 percent. Inaccuracies were due to human error (62 percent), flaws in system design (2 percent), or some combination of both (35 percent). Conclusions This study highlights the high accuracy of patient self-reported R/E/A/L data entry and identifies some areas for improvement in staff training and technical system design to facilitate further progress. [ABSTRACT FROM AUTHOR]

To study the effects of payment timing, form of payment, and requiring a social security number (SSN) on survey response rates. Third-wave mailing of a U.S. physician survey. Nonrespondents were randomized to receive immediate U.S.$25 cash, immediate U.S.$25 check, promised U.S.$25 check, or promised U.S.$25 check requiring an SSN. Paper survey responses were double entered into statistical software. Response rates differed significantly between remuneration groups ( χ=80.1, p<.0001), with the highest rate in the immediate cash group (34 percent), then immediate check (20 percent), promised check (10 percent), and promised check with SSN (8 percent). Immediate monetary incentives yield higher response rates than promised in this population of nonresponding physicians. Promised incentives yield similarly low response rates regardless of whether an SSN is requested. [ABSTRACT FROM AUTHOR]

Objective. To examine adoption of telehealth in a rural public health district and to explain how the innovation became sustainable. Study Setting. Longitudinal, qualitative study (1988–2008) of the largest public health district in Georgia. Study Design. Case study design provided deep insights into the innovation's social dynamics. Punctuated equilibrium theory helped present and make sense of the process. We identified antecedent conditions and outcomes, and we distinguished between episodes and encounters based on the disruptive effects of events. Data Collection. Twenty-five semistructured interviews with 19 decision makers and professionals, direct observations, published papers, grant proposals, technical specifications, and other written materials. Principal Findings. Strong collaboration within the district, with local community, and with external partners energized the process. Well-functioning outreach clinics made telehealth desirable. Local champions cultivated participation and generative capability, and overcame barriers through opportunistic exploitation of technological and financial options. Telehealth usage fluctuated between medical and administrative operations in response to internal needs and contextual dynamics. External agencies provided initial funding and supported later expansion. Conclusions. Extensive internal and external collaboration, and a combination of technology push and opportunistic exploitation, can enable sustainable rural telehealth innovation. [ABSTRACT FROM AUTHOR]

Research Objective. This paper tests for differences in the effect of State Children's Health Insurance Program (SCHIP) on children's insurance coverage and physician visits across three age groups: pre-elementary school-aged children (pre-ESA), ESA children, and post-ESA children. Data Source. The study uses two cross sections of the Survey of Income and Program Participation (SIPP) from the 1996 and 2001 panels. Study Design. A difference-in-differences approach is used to estimate the effect of SCHIP on coverage and physician visits of newly eligible children of different age groups. Data Collection. Demographic, insurance, and physician visit information for children in families with income below 300 percent of federal poverty line were extracted from the SIPP. Principal Findings. Uninsurance rates for post-ESA children declined due to SCHIP while public coverage and the likelihood of visiting a physician increased. Estimates of cross-age differences show that post-ESA children experienced a larger decline in uninsurance rates compared with pre-ESA and ESA children and a larger increase in physician visits compared with ESA children. Conclusions. The higher rate of physician visits for post-ESA children due to SCHIP demonstrates the importance of extending insurance coverage to teens as well as young children. [ABSTRACT FROM AUTHOR]

Objective. To examine the within-year concentration of family health care and the resulting exposure of families to short periods of high expenditure burdens. Data Source. Household data from the pooled 2003 and 2004 Medical Expenditure Panel Survey (MEPS) yielding nationally representative estimates for the nonelderly civilian noninstitutionalized population. Study Design. The paper examines the within-year concentration of family medical care use and the frequency with which family out-of-pocket expenditures exceeded 20 percent of family income, computed at the annual, quarterly, and monthly levels. Principal Findings. On average among families with medical care, 49 percent of all (charge-weighted) care occurred in a single month, and 63 percent occurred in a single quarter). Nationally, 27 percent of the study population experienced at least 1 month in which out-of-pocket expenditures exceeded 20 percent of income. Monthly 20 percent burden rates were highest among the poor, at 43 percent, and were close to or above 30 percent for all but the highest income group (families above four times the federal poverty line). Conclusions. Within-year spikes in health care utilization can create financial pressures missed by conventional annual burden analyses. Within-year health-related financial pressures may be especially acute among lower-income families due to low asset holdings. [ABSTRACT FROM AUTHOR]

The article discusses various reports published within the issue, including one on the methodological approach taken by the Patient Safety Evaluation Center, and another on the successes of projects conducted under the U.S. Agency for Healthcare Research and Quality's (AHRQ) leadership.

Objective. To describe the development of an instrument for assessing workforce perceptions of hospital safety culture and to assess its reliability and validity. Data Sources/Study Setting. Primary data collected between March 2004 and May 2005. Personnel from 105 U.S. hospitals completed a 38-item paper and pencil survey. We received 21,496 completed questionnaires, representing a 51 percent response rate. Study Design. Based on review of existing safety climate surveys, we developed a list of key topics pertinent to maintaining a culture of safety in high-reliability organizations. We developed a draft questionnaire to address these topics and pilot tested it in four preliminary studies of hospital personnel. We modified the questionnaire based on experience and respondent feedback, and distributed the revised version to 42,249 hospital workers. Data Collection. We randomly divided respondents into derivation and validation samples. We applied exploratory factor analysis to responses in the derivation sample. We used those results to create scales in the validation sample, which we subjected to multitrait analysis (MTA). Principal Findings. We identified nine constructs, three organizational factors, two unit factors, three individual factors, and one additional factor. Constructs demonstrated substantial convergent and discriminant validity in the MTA. Cronbach's α coefficients ranged from 0.50 to 0.89. Conclusions. It is possible to measure key salient features of hospital safety climate using a valid and reliable 38-item survey and appropriate hospital sample sizes. This instrument may be used in further studies to better understand the impact of safety climate on patient safety outcomes. [ABSTRACT FROM AUTHOR]

Objective. This paper analyzes whether the rise in managed care during the 1990s caused the increase in hospital concentration. Data Sources. We assemble data from the American Hospital Association, InterStudy and government censuses from 1990 to 2000. Study Design. We employ linear regression analyses on long differenced data to estimate the impact of managed care penetration on hospital consolidation. Instrumental variable analogs of these regressions are also analyzed to control for potential endogeneity. Data Collection. All data are from secondary sources merged at the level of the Health Care Services Area. Principle Findings. In 1990, the mean population-weighted hospital Herfindahl–Hirschman index (HHI) in a Health Services Area was .19. By 2000, the HHI had risen to .26. Most of this increase in hospital concentration is due to hospital consolidation. Over the same time frame HMO penetration increased three fold. However, our regression analysis strongly implies that the rise of managed care did not cause the hospital consolidation wave. This finding is robust to a number of different specifications. [ABSTRACT FROM AUTHOR]

The article offers a rejoinder to Roice D. Luke's paper on taxonomy of health networks and systems in the U.S. The authors stress that their primary objective in developing health care system taxonomy was to analyze health networks' structure and strategy as defined by the American Hospital Association. The taxonomy proponents clarified all issues raised by Luke such as the relevance of conceptual framework to health networks and the existence of measurement errors.

Objectives. Veterans Affairs (VA) patient populations are becoming increasingly diverse in race and ethnicity. The purpose of this paper is to (1) document the importance of using consistent standards of conceptualizing and categorizing race and ethnicity in health services research, (2) provide an overview of different methods currently used to assess race and ethnicity in health services research, and (3) suggest assessment methods that could be incorporated into health services research to ensure accurate assessment of disease prevalence and incidence, as well as accounts of appropriate health services use, in patients with different racial and ethnic backgrounds. Design. A critical review of published literature was used. Principal Findings. Race is a complex, multidimensional construct. For some individuals, institutionalized racism and internalized racism are intertwined in the effects of race on health outcomes and health services use. Ethnicity is most commonly used as a social–political construct and includes shared origin, shared language, and shared cultural traditions. Acculturation appears to affect the strength of the relationships among ethnicity, health outcomes, and health services use. Conclusions. Improved and consistent methods of data collection need to be developed for use by VA researchers across the country. VA research sites with patients representing specific population groups could use a core set of demographic items in addition to expanded modules designed to assess the ethnic diversity within these population groups. Improved and consistent methods of data collection could result in the collection of higher-quality data, which could lead to the identification of race- and ethnic-specific health services needs. These investigations could in turn lead to the development of interventions designed to reduce or eliminate these disparities. [ABSTRACT FROM AUTHOR]

Cogitates the challenges of studying the effects of managed care in the U.S. Changes to managed care plans in the medical care practice; Decline in the utilization management strategies; Impact of the reductions in selective contracting to health maintenance organizations.

Objective: To estimate the impact of the major components of the ACA (Medicaid expansion, subsidized Marketplace plans, and insurance market reforms) on disparities in insurance coverage after three years.Data Source: The 2011-2016 waves of the American Community Survey (ACS), with the sample restricted to nonelderly adults.Design: We estimate a difference-in-difference-in-differences model to separately identify the effects of the nationwide and Medicaid expansion portions of the ACA using the methodology developed in the recent ACA literature. The differences come from time, state Medicaid expansion status, and local area pre-ACA uninsured rates. In order to focus on access disparities, we stratify our sample separately by income, race/ethnicity, marital status, age, gender, and geography.Principal Findings: After three years, the fully implemented ACA eliminated 43% of the coverage gap across income groups, with the Medicaid expansion accounting for this entire reduction. The ACA also reduced coverage disparities across racial groups by 23%, across marital status by 46%, and across age-groups by 36%, with these changes being partly attributable to both the Medicaid expansion and nationwide components of the law.Conclusions: The fully implemented ACA has been successful in reducing coverage disparities across multiple groups. [ABSTRACT FROM AUTHOR]

Objectives: To determine dementia prevalence and costs attributable to dementia using Veterans Health Administration (VHA) data with and without Medicare data.Data Sources: VHA inpatient, outpatient, purchased care and other data and Medicare enrollment, claims, and assessments in fiscal year (FY) 2013.Study Design: Analyses were conducted with VHA data alone and with combined VHA and Medicare data. Dementia was identified from a VHA sanctioned list of ICD-9 diagnoses. Attributable cost of dementia was estimated using recycled predictions.Data Collection: Veterans age 65 and older who used VHA and were enrolled in Traditional Medicare in FY 2013 (1.9 million).Principal Findings: VHA records indicated the prevalence of dementia in FY 2013 was 4.8 percent while combined VHA and Medicare data indicated the prevalence was 7.4 percent. Attributable cost of dementia to VHA was, on average, $10,950 per veteran per year (pvpy) using VHA alone and $6,662 pvpy using combined VHA and Medicare data. Combined VHA and Medicare attributable cost of dementia was $11,285 pvpy. Utilization attributed to dementia using VHA data alone was lower for long-term institutionalization and higher for supportive care services than indicated in combined VHA and Medicare data.Conclusions: Better planning for clinical and cost-efficient care requires VHA and Medicare to share data for veterans with dementia and likely more generally. [ABSTRACT FROM AUTHOR]

Objective (Study Question): To use systems thinking with diverse system actors to (a) characterize current problems at the intersection of chronic conditions (CCs) and reproductive health (RH) care and their determinants, (b) determine necessary system actors for change, and (c) document cross‐system actions that can improve identified problems in the United States. Data Sources/Study Setting: Data were collected from six groups of system actors via online focus groups. Study Design: This is a qualitative multilevel study using the iceberg systems thinking framework. Data Collection/Extraction Methods: Data were collected by note‐taking and recording six focus groups; analysis incorporated perspective triangulation using the systems thinking iceberg and system mapping to visualize interconnected system challenges, actors, and action ideas. Principal Findings: Participants described eight necessary system actors: health care institutions, medical leaders, medical providers, patient advocates and foundations, patients and families, payors, policy makers, and research funders. Forty pain points were identified, spread across each of the four levels of the systems thinking iceberg: undesirable outcomes (6), concerning trends (9), system structure flaws (15), and problematic mental models (10). In response to these pain points, a set of 46 action ideas was generated by participants and mapped into nine action themes: (1) adjust QI metrics, incentives, and reimbursement, (2) bolster RH medical education and training, (3) break down medical silos, (4) enrich patient education, (5) expand the health care team, (6) improve holistic health care, (7) modify research and programmatic funding to prioritize RH and CC, (8) spur innovation for patient visits, and (9) support professional champions and leaders. Conclusions: By embracing system complexity, creating visual maps, and pushing participants to identify actionable strategies for improvement, this study generates a set of specific actions that can be used to address pain points across the multiple system levels that make improving reproductive care for people with CCs so challenging. [ABSTRACT FROM AUTHOR]

Objective: To identify and describe the standardized interconception and preconception screening tools for reproductive health needs that are applicable in general outpatient clinical practice. Data Sources and Study Setting: This systematic review identifies research on pregnancy intention screening and counseling tools, and standardized approaches to preconception and interconception care. We focus on tools designed for clinical settings, but also include research tools with potential for clinical implementation. These tools may include a component of contraceptive counseling, but those focusing solely on contraceptive counseling were excluded. Data were collected from studies done in the United States between January 2000 and March 2022. Study Design: We performed a systematic literature search to generate a list of unique tools, assessed the quality of evidence supporting each tool, and described the peer‐reviewed clinical applications of each. We used the Mixed Methods Appraisal Tool to appraise the quality of individual studies. Data Collection/Extraction Methods: We searched PubMed, Web of Science, and CINAHL databases for standardized preconception and interconception health screening tools published in English from January 2000 through March 2022. We used keywords "preconception care," "interconception care," "family planning," "contraception," "reproductive health services," and "counseling." Utilizing the Preferred Reporting Items for Systematic Reviews guidelines, we screened titles and abstracts to identify studies for full text review. Principal Findings: The search resulted in 15,399 studies. After removing 4172 duplicates, we screened 11,227 titles/abstracts and advanced 207 for full‐text review. From these, we identified 53 eligible studies representing 22 tools/standardized approaches, of which 10 had evidence from randomized clinical trials. These ranged widely in design, setting, and population of study. Conclusions: Clinicians have a choice of tools when implementing standard reproductive screening services. A growing body of research can inform the selection of an appropriate tool, and more study is needed to establish effects on long‐term patient outcomes. [ABSTRACT FROM AUTHOR]

The article discusses the role of state regulators and insurance companies in the U.S. in the U.S. Affordable Care Act to shape the markets and determine insurance plan affordability by referring to the article, Individual Market Health Plan Affordability after Cost Sharing Reduction Subsidy Cuts, published within the issue. Topics discussed include the affordability of the individual health insurance market, the termination of payments for cost-sharing reduction, and Medicaid expansion.

Objective: To examine the effects of hospital and insurer markets concentration on transaction prices for inpatient hospital services.Data Sources: Measures of hospital and insurer markets concentration derived from American Hospital Association and HealthLeaders-InterStudy data are linked to 2005-2008 inpatient administrative data from Truven Health MarketScan Databases.Study Design: Uses a reduced-form price equation, controlling for cost and demand shifters and accounting for possible endogeneity of market concentration using instrumental variables (IV) technique.Principal Findings: The findings suggest that greater hospital concentration raises prices, whereas greater insurer concentration depresses prices. A hypothetical merger between two of five equally sized hospitals is estimated to increase hospital prices by about 9 percent (p < .001). A similar merger of insurers would depress prices by about 15.3 percent (p < .001). Over the 2003-2008 periods, the estimates imply that hospital consolidation likely raised prices by about 2.6 percent, while insurer consolidation depressed prices by about 10.8 percent. Additional analysis using longer panel data and applying hospital fixed effects confirms the impact of hospital concentration on prices.Conclusion: The findings provide support for strong antitrust enforcement to curb rising hospital service prices and health care costs. [ABSTRACT FROM AUTHOR]

Objective: To test how Certificate of Need laws affect all‐cause mortality in the United States. Data Sources: The data of 1992–2011 all‐cause mortality are from the Center for Disease Control's Compressed Mortality File; control variables are from the Current Population Survey, Behavioral Risk Factor Surveillance System, and Area Health Resources File; and data on Certificate of Need laws are from Stratmann and Russ ( ). Study design: Using fixed‐ and random‐effects regressions, I test how the scope of state Certificate of Need laws affects all‐cause mortality within US counties. Principal Findings: Certificate of Need laws have no statistically significant effect on all‐cause mortality. Point estimates indicate that if they have any effect, they are more likely to increase mortality than decrease it. Conclusions: Proponents of Certificate of Need laws have claimed that they reduce mortality by concentrating more care into fewer, larger facilities that engage in learning‐by‐doing. However, I find no evidence that these laws reduce all‐cause mortality. [ABSTRACT FROM AUTHOR]

The authors analyze the relationship between acute and postacute medical care in the U.S. The authors discuss the problems associated with patient transition between acute and postacute care settings and the medical policies that have been implemented to reduce fragmentation between the two patient care settings. They recommend their own solutions to reducing fragmentation, including integrating acute and postacute care into a single financial entity.

Objective: To advance equity by developing stakeholder‐driven principles of shared measurement, which is using a common set of measurable goals that reflect shared priorities across communities and systems, such as health care, public health, and human and social services. Data Sources: From October 2019 to July 2021, we collected primary data from leaders in cross‐systems alignment, measurement, and community engagement—including community members and community‐based organization leaders—across the United States. Study Design: In partnership with equity and community engagement experts, we conducted a mixed‐methods study that included multiple formative research activities and culminated in a six‐week, stakeholder‐engaged modified‐Delphi process. Data Collection: Formative data collection occurred through an environmental scan, interviews, focus groups, and an online survey. Principles were developed using a virtual modified Delphi with iterative rapid‐analysis. Feedback on the final principles was collected through virtual focus groups, an online feedback form, and during virtual presentations. Principal Findings: We developed a set of five guiding principles. Measurement that aligns systems with communities toward equitable outcomes: (1) Requires upfront investment in communities; (2) Is co‐created by communities; (3) Creates accountability to communities for addressing root causes of inequities and repairing harm; (4) Focuses on a holistic and comprehensive view of communities that highlights assets and historical context; and (5) Reflects long‐term efforts to build trust. Using an equity‐focused process resulted in principles with broad applicability. Conclusions: Leaders across systems and communities can use these shared measurement principles to reimagine and transform how systems create equitable health by centering the needs and priorities of the communities they serve, particularly communities that historically have been harmed the most by inequities. Intentionally centering equity across all project activities was essential to producing principles that could guide others in advancing equity. [ABSTRACT FROM AUTHOR]

Objective: To provide guidelines to researchers measuring health expenditures by disease and compare these methodologies' implied inflation estimates.Data Source: A convenience sample of commercially insured individuals over the 2003 to 2007 period from Truven Health. Population weights are applied, based on age, sex, and region, to make the sample of over 4 million enrollees representative of the entire commercially insured population.Study Design: Different methods are used to allocate medical-care expenditures to distinct condition categories. We compare the estimates of disease-price inflation by method.Principal Findings: Across a variety of methods, the compound annual growth rate stays within the range 3.1 to 3.9 percentage points. Disease-specific inflation measures are more sensitive to the selected methodology.Conclusion: The selected allocation method impacts aggregate inflation rates, but considering the variety of methods applied, the differences appear small. Future research is necessary to better understand these differences in other population samples and to connect disease expenditures to measures of quality. [ABSTRACT FROM AUTHOR]

Objective: To evaluate whether primary care physicians' participation in the Medicare Shared Savings Program (MSSP) is associated with changes in their preventive services delivery.Data Sources: Medicare Provider Utilization and Payment Physician and Other Supplier Public Use File and MSSP Accountable Care Organizations (ACO) Provider-Level Research Identifiable File from 2012 to 2018.Study Design: The design was a two-way fixed effects model estimating within-provider changes in preventive services delivery over time controlling for provider time-invariant characteristics, national time trends, and characteristics of served patients. The following preventive services were evaluated: influenza vaccination, pneumococcal vaccination, clinical depression screening, colorectal cancer screening, breast cancer screening, Body Mass Index (BMI) screening and follow-up, tobacco use assessment, and annual wellness visits. Both the likelihood of providing services and the volume of services delivered were evaluated.Data Collection/extraction Methods: Secondary data linked at the provider level.Principal Findings: MSSP participation was associated with an increase in the likelihood of providing influenza vaccination (0.7 percentage-points), pneumococcal vaccination (2.0 percentage-points), clinical depression screening (2.1 percentage-points), tobacco use assessment (0.3 percentage-points), and annual wellness visits (4.1 percentage-points). A similar increase was found for the volume of services delivered per 100 patients for several preventive services: influenza vaccination (0.18), pneumococcal vaccination (0.56), clinical depression screening (0.46), and annual wellness visits (1.52). MSSP participation was associated with a decrease in the likelihood (-0.4 percentage-points) and the volume of colorectal cancer screening (-0.03).Conclusions: Primary care physicians' participation in MSSP was associated with an increase in the likelihood and the volume of several preventive services. [ABSTRACT FROM AUTHOR]

Objective: To investigate how the health services research (HSR) workforce supply in the United States has evolved over the last 5 years. Data Sources: Membership data of AcademyHealth participants, professional networking websites, PubMed, grant databases, and the Integrated Postsecondary Education Data System. Study Design: Descriptive study comparing size and characteristics of the HSR workforce and graduates identified across multiple data sources. Lists of authors and principal investigators (PIs) were merged and de‐duplicated to identify unique counts. Pearson's chi‐squared test was used to compare characteristics between members and nonmembers of AcademyHealth. Data Collection: Downloaded files from websites and received survey data extracted by AcademyHealth between 2016 and 2020. Principal Findings: The workforce size ranged from 9610 to 28,136, depending on data source. Common employers included universities, government settings, and health systems. Little overlap in employers existed for individuals with potentially competing skill sets. The HSR workforce appeared more diverse than the US adult population, with two to three times greater representation among Asian individuals yet lower representation among Black/African American (30%) and Hispanic (75%) individuals compared with the US population. Exactly 87,721 master's and 3105 doctoral degree graduates from core HSR fields were added over 5 years from public and not‐for‐profit institutions. Including for‐profit institution graduates increased the count by 15% for master's and 30% for doctoral graduates. Hispanic (any race), Black/African American, and multiracial individuals gained representation among core HSR graduates, with for‐profit institutions substantially contributing to the number of Black/African American graduates. Conclusions: The HSR workforce is growing with increasing diversity among its graduates compared with previous studies. Additional work is needed to understand how employers value the contributions of those trained in HSR. Continued efforts are needed to ensure HSR workforce diversity to frame critical research questions and develop programs and policies that reflect the needs of the community. [ABSTRACT FROM AUTHOR]

Objective: Several studies of nurse staffing and patient outcomes found a curvilinear or U‐shaped relationship, with benefits from additional nurse staffing diminishing or reversing at high staffing levels. This study examined potential diminishing returns to nurse staffing and the existence of a "tipping point" or the level of staffing after which higher nurse staffing no longer improves and may worsen readmissions. Data Sources/Study Setting: The Readiness Evaluation And Discharge Interventions (READI) study database of over 130,000 adult (18+) inpatient discharges from 62 medical, surgical, and medical‐surgical (noncritical care) units from 31 United States (US) hospitals during October 2014–March 2017. Study Design: Observational cross‐sectional study using a fully nonparametric random forest machine learning method. Primary exposure was nurse hours per patient day (HPPD) broken down by registered nurses (nonovertime and overtime) and nonlicensed nursing personnel. The outcome was 30‐day all‐cause same‐hospital readmission. Partial dependence plots were used to visualize the pattern of predicted patient readmission risk along a range of unit staffing levels, holding all other patient characteristics and hospital and unit structural variables constant. Data Collection/Extraction methods: Secondary analysis of the READI data. Missing values were imputed using the missing forest algorithm in R. Principal Findings: Partial dependence plots were U‐shaped, showing the readmission risk first declining and then rising with additional nurse staffing. The tipping points were at 6.95 and 0.21 HPPD for registered nurse staffing (nonovertime and overtime, respectively) and 2.91 HPPD of nonlicensed nursing personnel. Conclusions: The U‐shaped association was consistent with diminishing returns to nurse staffing suggesting that incremental gains in readmission reduction from additional nurse staffing taper off and could reverse at high staffing levels. If confirmed in future causal analyses across multiple outcomes, accompanying investments in infrastructure and human resources may be needed to maximize nursing performance outcomes at higher levels of nurse staffing. [ABSTRACT FROM AUTHOR]

Objective. To develop a composite measure of state-level malpractice environment. Data Sources. Public use data from the National Practitioner Data Bank, Medical Liability Monitor, the National Conference of State Legislatures, and the American Bar Association. Study Design. Principal component analysis of state-level indicators (paid claims rate, malpractice premiums, lawyers per capita, average award size, and malpractice laws), with indirect validation of the composite using receiver-operating characteristic curves to determine how accurately the composite could identify states with high-tort activity and costs. Principal Findings. A single composite accounted for over 73 percent of total variance in the seven indicators and demonstrated reasonable criterion validity. Conclusion. An empirical composite measure of state-level malpractice risk may offer advantages over single indicators in measuring overall risk and may facilitate cross-state comparisons of malpractice environments. [ABSTRACT FROM AUTHOR]

Objectives: To compare patterns of technological adoption of minimally invasive surgery for radical prostatectomy across the United States and England. Data Sources: We examine radical prostatectomy in the United States and England between 2005 and 2017, using de‐identified administrative claims data from the OptumLabs Data Warehouse in the United States and the Hospital Episodes Statistics in England. Study Design: We conducted a longitudinal analysis of robotic, laparoscopic, and open surgery for radical prostatectomy. We compared the trends of adoption over time within and across countries. Next, we explored whether differential adoption patterns in the two health systems are associated with differences in volumes and patient characteristics. Finally, we explored the relationship between these adoption patterns and length of stay, 30‐day readmission, and urology follow‐up visits. Data Collection: Open, laparoscopic, and robotic radical prostatectomies are identified using Office of Population Censuses and Surveys Classification of Interventions and Procedures (OPCS) codes in England and International Classification of Diseases ninth revision (ICD9), ICD10, and Current Procedural Terminology (CPT) codes in the United States. Principal Findings: We identified 66,879 radical prostatectomies in England and 79,358 in the United States during 2005–2017. In both countries, open surgery dominates until 2009, where it is overtaken by minimally invasive surgery. The adoption of robotic surgery is faster in the United States. The adoption rates and, as a result, the observed centralization of volume, have been different across countries. In both countries, patients undergoing radical prostatectomies are older and have more comorbidities. Minimally invasive techniques show decreased length of stay and 30‐day readmissions compared to open surgery. In the United States, robotic approaches were associated with lower length of stay and readmissions when compared to laparoscopic. Conclusions: Robotic surgery has become the standard approach for radical proctectomy in the United States and England, showing decreased length of stay and in 30‐day readmissions compared to open surgery. Adoption rates and specialization differ across countries, likely a product of differences in cost‐containment efforts. [ABSTRACT FROM AUTHOR]

In this article the author discusses aspects of the study conducted by Jeffrey H. Silber and colleagues on the ecological relationship between hospital's intensity, and rates of operative complications and failure-to-rescue from complications. The author relates that the study found a link between increased hospital intensity and lower postadmission mortality, and has implications for health care reform. Moreover, it highlights the importance of improving U.S. population health.

Objective. Describe the evaluation performed of the patient safety initiative operated by the Agency for Healthcare Research and Quality (AHRQ). AHRQ Patient Safety Initiative. When patient safety became a national priority in 2000, Congress charged and funded AHRQ to improve health care safety. Over the next 6 years, AHRQ funded more than 300 research projects and other activities, addressing diverse patient safety issues and practices. The Patient Safety Evaluation. AHRQ contracted with RAND in 2002 to perform a 4-year evaluation of the initiative, which was completed in 2006. This formative evaluation used the CIPP program evaluation model, which emphasizes multiple stakeholders' interests (e.g., patients, providers, funded researchers). We monitored the progress of the patient safety initiative and provided AHRQ annual feedback that assessed each year's activities, identifying issues and offering suggestions for actions by AHRQ. Given the size and complexity of the initiative, the evaluation needed to examine key individual components and synthesize results across them, and it also had to be responsive to changes in the initiative over time. We used a conceptual framework to bring together the disparate pieces to synthesize overall findings. The remaining articles in this issue describe selected results from this evaluation. [ABSTRACT FROM AUTHOR]

An introduction is presented on the theme "The Best of the 2015 AcademyHealth Annual Research Meeting."

The author reflects on the impact of medicare coverage policies on health care utilization in the U.S. The author states that there are significant limitations to enforcement of coverage policies in the U.S. He notes that coverage decisions vary when there is no consensus about whether a particular procedure is effective. Furthermore, a suggestion to medicare carriers to focus their efforts on the elimination of forms of care that are inappropriate is presented.