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Objective: To examine how a novel payer-provider joint venture (JV) between one payer and multiple competitive delivery systems in New Hampshire (NH), which included value-based payment, care management, and non-financial supports, impacted healthcare value and payer and provider group experiences., Study Setting and Design: We conducted a mixed-methods study. We used a quasi-experimental longitudinal difference-in-differences design to examine the impact of the JV (which started in January 2016 and ended in December 2020) on healthcare utilization, quality, and spending, using members in Maine (ME) as a control group. We also analyzed patient uptake of the JV's care management program using routinely collected administrative data and assessed payer and provider group leaders' perspectives about the JV via semi-structured interviews., Data Sources and Analytic Sample: We used administrative and claims data from 2013 to 2019 in a commercially insured population under 65 years in NH and ME. We also used administrative data on care management eligibility and uptake and conducted semi-structured interviews with payer and provider group leaders affiliated with the JV., Principal Findings: The JV was associated with no sustained change in medical utilization, quality, and spending throughout the study period. In the first year of the JV, there was a $142 (95% confidence interval: $41, $243) increase in pharmaceutical spending per member and a 13% (4.4%, 25%) relative increase in days covered for diabetes medications. Only 15% of eligible members engaged in care management, which was a key component of the JV's multi-pronged approach. In a disconnect from the empirical findings, payer and provider group leaders believed that the JV reduced healthcare costs and improved quality., Conclusions: Our findings provide evidence for future payer-provider JVs and demonstrate the importance of having a valid control group when evaluating JVs and value-based payment arrangements., (© 2024 Health Research and Educational Trust.)

Objective: To examine the response of community health center (CHC) quality to quality levels at neighboring CHCs in the presence of non-price competition., Data Setting and Design: A quasi-experimental study of US community health centers. Outcome variables were indices that measured overall quality of CHC care. Using patient flow data, we constructed CHC-specific Hirschman-Herfindahl index (HHI) and competitors' composite quality measure. The plausibly exogenous change in characteristics of "competitors' competitors" was exploited to identify the relationship between competition and quality of care, using a generalized two-stage least square model with instrumental variables., Data Sources and Analytic Sample: Using the Health Center Program Uniform Data System (2014-2018), linked with American Community Survey and Medical Expenditure Panel Survey, we analyzed 1098 unique federally funded CHCs in 50 states and District of Columbia which had at least one neighboring CHC and had non-missing data for 2015-2018 (4226 CHC-years)., Principal Findings: Most of CHCs served populations in overlapping geographic markets, with median market concentration decreasing during the study period. A one-percent increase in competitors' quality was associated with a 0.71-percent increase in an index CHC's composite quality (p < 0.01), consisting of a 0.59-percent increase in chronic condition control rates (p < 0.01); a 0.68-percent increase in the screening and assessment rates (p < 0.01); and a 0.78-percent increase in medication management rates (p < 0.01). The association was stronger at CHCs serving a smaller proportion of uninsured patients. No significant quality reaction was observed at CHCs with a percentage of uninsured patients larger than the 75th percentile. We observed no significant associations between HHI and quality., Conclusions: Increasing competition does not harm quality of care at CHCs. A CHC appears to improve its quality if its competitors improved quality. The beneficial quality effect was less pronounced in CHCs providing a significant proportion of care to uninsured patients, suggesting lack of incentives faced by these CHCs., (© 2024 Health Research and Educational Trust.)

Objective: The 2020 Family First Coronavirus Response Act (FFCRA) extended Medicaid coverage for enrollees without rechecking eligibility. Before that, women were eligible for Medicaid coverage up to 60 days postpartum. We examine the FFCRA's effect on Medicaid postpartum coverage, depression symptoms, and birth control use beyond 60 days after delivery., Data Sources and Setting: We use data from the 2016-2021 Pregnancy Risk Assessment Monitoring System (PRAMS). The primary sample includes 56,828 women who were income eligible up to 60 days postpartum or beyond in their state., Study Design: We employ a difference-in-differences design comparing outcomes before and after the FFCRA between women who were not income eligible for Medicaid coverage beyond 60 days postpartum in their state and those who were income eligible. We estimate models without and with controlling for state-specific trends in outcomes over time., Data Collection/extraction Methods: N/A., Principal Findings: There is an 8.1 percentage-point increase in the likelihood of having Medicaid coverage without controlling for state-specific trends, and 5.4 percentage-points when controlling for state-specific trends (both p < 0.05). There is a decline in likelihood of being uninsured by 3 percentage-points (p < 0.05) without state-specific trends and a smaller and non-significant decline when including state-specific trends. Estimated effects on depression symptoms and birth control use are small and statistically non-significant., Conclusion: Following the FFCRA, there was an increase in Medicaid coverage beyond 60 days postpartum among women who would have been income ineligible for Medicaid after 60 days. However, there is a less pronounced effect on likelihood of being uninsured, which might be partly due to some switching from private to Medicaid coverage. There were no discernable effects on depression symptoms and birth control use. Examining additional health and health care utilization measures over a longer postpartum period is needed to further understand the FCCRA effects on these outcomes., (© 2024 The Author(s). Health Services Research published by Wiley Periodicals LLC on behalf of Health Research and Educational Trust.)

Objective: To investigate primary care practice ownership and specialist-use patterns for commercially insured children with disabilities., Data Sources and Study Setting: A national commercial claims database and the Health Systems and Provider Database from 2012 to 2016 are the data sources for this study., Study Design: This cross-sectional, descriptive study examines: (1) the most visited type of pediatric primary care physician and practice (independent or system-owned); (2) pediatric and non-pediatric specialist-use patterns; and (3) how practice ownership relates to specialist-use patterns., Data Collection/extraction Methods: This study identifies 133,749 person-years of commercially insured children with disabilities aged 0-18 years with at least 24 months of continuous insurance coverage by linking a national commercial claims data set with the Health Systems and Provider Database and applying the validated Children with Disabilities Algorithm., Principal Findings: Three-quarters (75.9%) of children with disabilities received their pediatric primary care in independent practices. Nearly two thirds (59.6%) used at least one specialist with 45.1% using nonpediatric specialists, 28.8% using pediatric ones, and 17.0% using both. Specialist-use patterns varied by both child age and specialist type. Children with disabilities in independent practices were as likely to see a specialist as those in system-owned ones: 57.1% (95% confidence interval [95% CI] 56.7%-57.4%) versus 57.3% (95% CI 56.6%-58.0%), respectively (p = 0.635). The percent using two or more types of specialists was 46.1% (95% CI 45.4%-46.7%) in independent practices, comparable to that in systems 47.1% (95% CI 46.2%-48.0%) (p = 0.054). However, the mean number of specialist visits was significantly lower in independent practices than in systems-4.0 (95% CI 3.9%-4.0%) versus 4.4 (95% CI 4.3%-4.6%) respectively-reaching statistical significance with p < 0.0001., Conclusions: Recognizing how privately insured children with disabilities use pediatric primary care from pediatric and nonpediatric primary care specialists through both independent and system-owned practices is important for improving care quality and value., (© 2023 Health Research and Educational Trust.)

Objective: To examine indirect spillover effects of Affordable Care Act (ACA) Medicaid expansions to working-age adults on health care coverage, spending, and utilization by older low-income Medicare beneficiaries., Data Sources: 2010-2018 Health and Retirement Study survey data linked to annual Medicare beneficiary summary files., Study Design: We estimated individual-level difference-in-differences models of total spending for inpatient, institutional outpatient, physician/professional provider services; inpatient stays, outpatient visits, physician visits; and Medicaid and Part A and B Medicare coverage. We compared changes in outcomes before and after Medicaid expansion in expansion versus nonexpansion states., Data Collection/extraction Methods: The sample included low-income respondents aged 69 and older with linked Medicare data, enrolled in full-year traditional Medicare, and residing in the community., Principal Findings: ACA Medicaid expansion was associated with a 9.8 percentage point increase in Medicaid coverage (95% CI: 0.020-0.176), a 4.4 percentage point increase in having any institutional outpatient spending (95% CI: 0.005-0.083), and a positive but statistically insignificant 2.4 percentage point change in Part B enrollment (95% CI: -0.003 to 0.050, p = 0.079)., Conclusions: ACA Medicaid expansion was associated with more institutional outpatient spending among older low-income Medicare beneficiaries. Increased care costs should be weighed against potential benefits from increased realized access to care., (© 2023 The Authors. Health Services Research published by Wiley Periodicals LLC on behalf of Health Research and Educational Trust.)

Objective: To assess the effects of hospital 340B eligibility on quality of inpatient care provided to Medicaid and uninsured patients and for all patients., Data: Agency for Health Care Research and Quality's Healthcare Cost and Utilization Project State Inpatient Data, Hospital Cost Reporting Information System Data, Office of Pharmacy Affairs Information System Data, and American Hospital Association Annual Survey., Design: Regression discontinuity design comparing hospitals just above the DSH percentage program eligibility threshold to those just below. Quality measures include all-cause mortality and 30-day readmission rates as well as condition-specific measures., Data Extraction: Inpatient data from general acute care hospitals from 2008 to 2014 in 15 states. Data linked on hospital 340B eligibility and participation., Principal Findings: We did not find discontinuities in inpatient care quality across the Program eligibility threshold for Medicaid and uninsured patients; specifically, on all-cause mortality (beta = -0.04 percentage points, 95% CI: -0.16, 0.08), 30-day readmission rates (beta = -0.16 percentage points, 95% CI: -0.81, 0.5), or other measures. Among insured and non-Medicaid patients, we found discontinuities for acute myocardial infarction (beta = -0.87 percentage points, 95% CI: -1.55, -0.2) and postoperative sepsis (beta = -0.15 percentage points, 95% CI: -0.23, -0.07) mortality., Conclusions: 340B Program participation has not demonstrated improved quality of inpatient care among Medicaid or uninsured patients., (© 2023 Health Research and Educational Trust.)

Objective: The aim of the study was to estimate the effect of the state-based reinsurance programs through the section 1332 State Innovation Waivers on health insurance marketplace premiums and insurer participation., Data Source: 2015 to 2022 Robert Wood Johnson Foundation Health Insurance Exchange Compare Datasets., Study Design: An event study difference-in-differences (DD) model separately for each year of implementation and a synthetic control method (SCM) are used to estimate year-by-year effects following program implementation., Data Collection/extraction Methods: Not applicable., Principal Findings: Reinsurance programs were associated with a decline in premiums in the first year of implementation by 10%-13%, 5%-19%, and 11%-17% for bronze, silver, and gold plans (p < 0.05). There is a trend of sustained declines especially for states that implemented their programs in 2019 and 2020. The SCM analyses suggest some effect heterogeneity across states but also premium declines across most states. There is no evidence that reinsurance programs affected insurer participation., Conclusion: State-based reinsurance programs have the potential to improve the affordability of health insurance coverage. However, reinsurance programs do not appear to have had an effect on insurer participation, highlighting the need for policy makers to consider complementary strategies to encourage insurer participation., (© 2023 The Authors. Health Services Research published by Wiley Periodicals LLC on behalf of Health Research and Educational Trust.)

Objective: To estimate the effect of nursing home closure on local employment, overall, and by rurality., Data Sources and Study Setting: We obtained 2008-2018 county-level data from the Quarterly Workforce Indicators, Medicare Provider of Services, Area Health Resource, and Urban Influence Codes files. From 2008 to 2018, 878 counties experienced at least one nursing home closure, and 2055 counties did not experience a closure., Study Design: Using a difference-in-difference study design, we compare the changes of total employment, health sector employment and non-health sector employment over time between counties with and without a nursing home closure. We utilize the variation in the year and quarter of nursing home closures to estimate subsequent employment changes as well as employment trends before closure. We also account for contemporaneous events including nursing home entries and hospital entries and closures, and evaluate heterogeneity by rurality., Data Extraction: We include data on nursing home closure from the Medicare Provider of Service file. Quarterly county-level employee counts were obtained from the Quarterly Workforce Indicators provided by the Census Bureau. County-level demographic data were obtained from the Area Health Resource Files. We use Urban Influence Codes from the Economic Research Service, Department of Agriculture, to classify metropolitan, micropolitan, and rural (noncore) counties., Principal Findings: Health sector employment decreased by about 3.2%-4.1% (p < 0.01) in counties with a nursing home closure. The reduction was largest in rural counties (approximately 7.2%-9.4%, p < 0.01). The reduction in health sector employment persisted over time, particularly in rural counties. Overall, there was no discernable effect on non-health sector employment., Conclusions: Nursing home closure is associated with a persistent decline in health sector employment, particularly in rural counties, suggesting a reduction in the health care workforce and in the ability to sustain health care services supply, particularly in rural areas., (© 2022 Health Research and Educational Trust.)

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., (© 2022 Health Research and Educational Trust.)

Objective: To determine whether the variation in prices paid for cardiac medical devices was associated with management practices in cardiac units., Study Setting: Cardiac units in US hospitals., Study Design: We regressed unit prices on management practice scores and other hospital characteristics, with and without controls for device fixed effects, for the 11 top-spending cardiac device categories., Data Collection: A trusted third party that had entered into a confidentiality agreement combined de-identified medical device price data for N = 213 US hospitals from ECRI's Supply Guide benchmarking service, with survey responses regarding management practices in those hospitals' cardiac units; the resulting merged data were made available to researchers for analysis with hospital identifiers removed. N = 1980 hospitals with interventional cardiac catheterization laboratories and at least 25 annual acute myocardial infarction discharges in 2010 were eligible for inclusion; N = 648 responded to the management practices survey; N = 213 subscribed to Supply Guide and purchased at least one of 11 top cardiac medical device categories., Principal Findings: Cardiac units with better management practices paid lower prices for cardiac devices (percent decrease in price for one standard deviation increase in management score = 1.33%, 95% confidence interval 0.99-1.67). This was comparable in magnitude to the price decrease associated with a one standard deviation increase in patient volume., Conclusions: Better management practices were associated with lower device prices. This relationship is robust, but modest in magnitude. This modest magnitude is similar, though, to other events expected to lower input prices, such as transparency in the form of benchmarking information and hospital mergers., (© 2021 Health Research and Educational Trust.)

Objective: Many employers have introduced rewards programs as a new benefit design in which employees are paid $25-$500 if they receive care from lower-priced providers. Our goal was to assess the impact of the rewards program on procedure prices and choice of provider and how these outcomes vary by length of exposure to the program and patient population., Study Setting: A total of 87 employers from across the nation with 563,000 employees and dependents who have introduced the rewards program in 2017 and 2018., Study Design: Difference-in-difference analysis comparing changes in average prices and market share of lower-priced providers among employers who introduced the reward program to those that did not., Data Collection Methods: We used claims data for 3.9 million enrollees of a large health plan., Principal Findings: Introduction of the program was associated with a 1.3% reduction in prices during the first year and a 3.7% reduction in the second year of access. Use of the program and price reductions are concentrated among magnetic resonance imaging (MRI) services, for which 30% of patients engaged with the program, 5.6% of patients received an incentive payment in the first year, and 7.8% received an incentive payment in the second year. MRI prices were 3.7% and 6.5% lower in the first and second years, respectively. We did not observe differential impacts related to enrollment in a consumer-directed health plan or the degree of market-level price variation. We also did not observe a change in utilization., Conclusions: The introduction of financial incentives to reward patients from receiving care from lower-priced providers is associated with modest price reductions, and savings are concentrated among MRI services., (© 2021 Health Research and Educational Trust.)

Objective: To describe physicians' variation in de-adopting concurrent statin and fibrate therapy for type 2 diabetic patients following a reversal in clinical evidence., Data Sources: We analyzed 2007-2015 claims data from OptumLabs ® Data Warehouse, a longitudinal, real-world data asset with de-identified administrative claims and electronic health record data., Study Design: We modeled fibrate use among Medicare Advantage and commercially insured type 2 diabetic statin users before and after the publication of the ACCORD lipid trial, which found statins and fibrates were no more effective than statins alone in reducing cardiovascular events among type 2 diabetic patients. We modeled fibrate use trends with physician random effects and physician characteristics such as age and specialty., Data Extraction: We identified patient-year-quarters with one year of continuous insurance enrollment, type 2 diabetes diagnoses, and fibrate use. We designated the physician most responsible for patients' diabetes care based on evaluation and management visits and prescriptions of glucose-lowering drugs., Principal Findings: Fibrate use increased by 0.12 percentage points per quarter among commercial patients (95% CI, 0.10 to 0.14) and 0.17 percentage points per quarter among Medicare Advantage patients (95% CI, 0.13 to 0.20) before the trial and then decreased by 0.16 percentage points per quarter among commercial patients (95% CI, -0.18 to -0.15) and 0.05 percentage points per quarter among Medicare Advantage patients (95% CI, -0.06 to -0.03) after the trial. However, 45% of physicians treating commercial patients and 48% of physicians treating Medicare Advantage patients had positive trends in prescribing following the trial. Physicians' characteristics did not explain their variation (pseudo R 2  = 0.000)., Conclusion: On average, physicians decreased fibrate prescribing following the ACCORD lipid trial. However, many physicians increased prescribing following the trial. Observable physician characteristics did not explain variations in prescribing. Future research should examine whether physicians vary similarly in other de-adoption settings., (© 2021 Health Research and Educational Trust.)

Objective: To estimate the impact of a large Medicare fee reduction for intensity-modulated radiation therapy (IMRT) on its use in prostate and breast cancer patients., Data Sources/study Setting: SEER-Medicare., Study Design: We compared trends in the use of IMRT between patients treated in practices directly affected by fee reductions (for prostate cancer, men treated in urology practices that own IMRT equipment; for breast cancer, women treated in freestanding radiotherapy clinics) and patients treated in other types of practices., Data Collection/extraction Methods: We identified breast and prostate cancer patients receiving IMRT using outpatient and physician office claims. We classified urology practices based on whether they billed for IMRT and radiotherapy clinics based on whether they were reimbursed under the Physician Fee Schedule., Principal Findings: Between 2006 and 2015 the payment for IMRT delivered in freestanding clinics and physician offices declined by $367 (-54.7%). However, the use of IMRT increased in physician practices subject to payment cuts, both in absolute terms and relative to use in practices unaffected by the payment cut. Use of IMRT in prostate cancer patients treated at urology practices that own IMRT equipment increased by 9.1 (95% CI: 2.0-16.2) percentage points between 2005 and 2016 relative to use in patients treated at other urology practices. Use of IMRT in breast cancer patients treated at freestanding radiotherapy centers increased by 7.5 (95% CI: -5.1 to 20.1) percentage points relative to use in patients treated at hospital-based centers., Conclusions: A steep decline in IMRT fees did not decrease IMRT use over the period from 2006 to 2015, though use has declined since 2010., (© 2021 Health Research and Educational Trust.)

Objective: To illustrate a method that accounts for sampling variation in identifying suppliers and counties with outlying rates of a particular pattern of inconsistent billing for ambulance services to Medicare., Data Sources: US Medicare claims for a 20% simple random sample of 2010-2014 fee-for-service beneficiaries., Study Design: We identified instances in which ambulance suppliers billed Medicare for transporting a patient to a hospital, but no corresponding hospital visit appeared in billing claims. We estimated the distributions of outlier supplier and county rates of such "ghost rides" by fitting a nonparametric empirical Bayes model with flexible distributional assumptions to account for sampling variation., Data Collection: We included Basic and advanced life support ground emergency ambulance claims with a hospital destination., Principal Findings: "Ghost ride" rates varied considerably across both ambulance suppliers and counties. We estimated 6.1% of suppliers and 5.0% of counties had rates that exceeded 3.6%, which was twice the national average of "ghost rides" (1.8% of all ambulance transports)., Conclusions: Health care fraud and abuse are frequently asserted but can be difficult to detect. Our data-driven approach may be a useful starting point for further investigation., (© 2021 Health Research and Educational Trust.)

Objective: To provide evidence on the effects of expansions to private and public insurance programs on adolescent specialty substance use disorder (SUD) treatment use., Data Source/study Setting: The Treatment Episodes Data Set (TEDS), 1996 to 2017., Study Design: A quasi-experimental difference-in-differences design using observational data., Data Collection: The TEDS provides administrative data on admissions to specialty SUD treatment., Principal Findings: Expansions of laws that compel private insurers to cover SUD treatment services at parity with general health care increase adolescent admissions by 26% (P < .05). These increases are driven by nonintensive outpatient admissions, the most common treatment episodes, which rise by 30% (P < .05) postparity law. In contrast, increases in income eligibility for public insurance targeting those 6-18 years old are not statistically associated with SUD treatment., Conclusions: Private insurance expansions allow more adolescents to receive SUD treatment, while public insurance income eligibility expansions do not appear to influence adolescent SUD treatment., (© 2020 Health Research and Educational Trust.)

Objective: To explore optimal workforce configurations in the production of care quality in community health centers (CHCs), accounting for interactions among occupational categories, as well as contributions to the volume of services., Data Sources: We linked the Uniform Data System from 2014 to 2016 with Internal Revenue Service nonprofit tax return data. The final database contained 3139 center-year observations from 1178 CHCs., Study Design: We estimated a system of two generalized linear production functions, with quality of care and volume of services as outputs, using the average percent of diabetic patients with controlled A1C level and hypertensive patients with controlled blood pressure as quality measures. To explore the substitutability and complementarity between staffing categories, we estimated a revenue function., Findings: Primary care physicians and advanced practice clinicians achieve similar quality outcomes (3.2 percent and 3.0 percent improvement in chronic condition management per full-time equivalent (FTE), respectively). Advanced practice clinicians generate less revenue per FTE but are generally less costly to employ., Conclusion: As quality incentives are further integrated into payment systems, CHCs will need to optimize their workforce configuration to improve quality. Given the relative efficiency of advanced practice clinicians in producing quality, further hiring of these professionals is a cost-effective investment for CHCs., (© 2020 Health Research and Educational Trust.)

Objective: To characterize physician health system membership in four states between 2012 and 2016 and to compare primary care quality and cost between in-system providers and non-system providers for the commercially insured population., Data Sources: Physician membership in health systems was obtained from a unique longitudinal database on health systems and matched at the provider level to 2014 all-payer claims data from Colorado, Massachusetts, Oregon, and Utah., Study Design: Using an observational study design, we compared physicians in health systems to non-system physicians located in the same state and geography on average cost of care (risk-adjusted using the Johns Hopkins' Adjusted Clinical Grouper), five HEDIS quality measures, one measure of developmental screening, and two Prevention Quality Indicator Measures., Data Collection/extraction Methods: Patients in commercial health plans were attributed to a primary care physician accounting for the plurality of office visits. A cohort for each quality measure was constructed based on appropriate measure specifications., Principal Findings: The share of physicians in health systems increased steadily from 2012 to 2016 and ranged from 48% in Colorado to 63% in Utah in 2016. Compared to physicians not in a system, system physicians performed similarly on most HEDIS quality metrics compared to non-system physicians. Patients attributed to in-system physicians had about 40% higher rates (P < .05) of Ambulatory Care Sensitive Admissions (measured in admissions per 100 000:921.33 in-system vs 674.61 not-in-system for acute composite; 2540.91 in-system vs 1972.17 for chronic composite In-system providers were associated with $29 (P < .05) higher average per member per month costs (453.37 vs 432.93). Overall, differences in performance by system membership were relatively small compared to differences across states and geography., Conclusion: A growing share of physicians is part of a health system from 2012 to 2016. Providers in health systems are not delivering primary care more efficiently than non-system providers for the commercially insured., (© Health Research and Educational Trust.)

Objective: To estimate the impact of the major components of the ACA (Medicaid expansion, subsidized Marketplace plans, and insurance market reforms) on health care access and self-assessed health during the first 2 years of the Trump administration (2017 and 2018)., Data Source: The 2011-2018 waves of the Behavioral Risk Factor Surveillance System (BRFSS), with the sample restricted to nonelderly adults. The BRFSS is a commonly used data source in the ACA literature due to its large number of questions related to access and self-assessed health. In addition, it is large enough to precisely estimate the effects of state policy interventions, with over 300 000 observations per year., Design: We estimate difference-in-difference-in-differences (DDD) models to separately identify the effects of the private and Medicaid expansion portions of the ACA using an identification strategy initially developed in Courtemanche et al (2017). The differences come from: (a) time, (b) state Medicaid expansion status, and (c) local area pre-2014 uninsured rates. We examine ten outcome variables, including four measures of access and six measures of self-assessed health. We also examine differences by income and race/ethnicity., Principal Findings: Despite changes in ACA administration and the political debate surrounding the ACA during 2017 and 2018, including these fourth and fifth years of postreform data suggests continued gains in coverage. In addition, the improvements in reported excellent health that emerged with a lag after ACA implementation continued during 2017 and 2018., Conclusions: While gains in access and self-assessed health continued in the first 2 years of the Trump administration, the ongoing debate at both the federal and state level surrounding the future of the ACA suggests the need to continue monitoring how the law impacts these and many other important outcomes over time., (© 2020 The Authors. Health Services Research published by Wiley Periodicals LLC on behalf of Health Research and Educational Trust.)

Objective: To test the effectiveness of physician incentives for increasing patient medication adherence in three drug classes: diabetes medication, antihypertensives, and statins., Data Sources: Pharmacy and medical claims from a large Medicare Advantage Prescription Drug Plan from January 2011 to December 2012., Study Design: We conducted a randomized experiment (911 primary care practices and 8,935 nonadherent patients) to test the effect of paying physicians for increasing patient medication adherence in three drug classes: diabetes medication, antihypertensives, and statins. We measured patients' medication adherence for 18 (6) months before (after) the intervention., Data Collection/extraction Methods: We obtained data directly from the health insurer., Principal Findings: We found no evidence that physician incentives increased adherence in any drug class. Our results rule out increases in the proportion of days covered by medication larger than 4.2 percentage points., Conclusions: Physician incentives of $50 per patient per drug class are not effective for increasing patient medication adherence among the drug classes and primary care practices studied. Such incentives may be more likely to improve measures under physicians' direct control rather than those that predominantly reflect patient behaviors. Additional research is warranted to disentangle whether physician effort is not responsive to these types of incentives, or medication adherence is not responsive to physician effort. Our results suggest that significant changes in the incentive amount or program design may be necessary to produce responses from physicians or patients., (© Health Research and Educational Trust.)

Objective: To provide new evidence on the effects of large-scale public health insurance expansions, associated with the Affordable Care Act (ACA), on the availability of specialty mental health care treatment in the United States. We measure availability with the probability that a provider accepts Medicaid., Data Source/study Setting: The National Mental Health Services Survey (N-MHSS) 2010-2018., Study Design: A quasi-experimental differences-in-differences design using observational data., Data Collection: The N-MHSS provides administrative data on the universe of specialty mental health care providers in the United States. Response rates are above 90 percent in all years. Data cover 85 019 provider/year observations., Principal Findings: ACA-Medicaid expansion increases the probability that a provider accepts Medicaid by 1.69 percentage points, 95 percent confidence interval: [0.0017,0.0321], which corresponds to an increase from 87.27 percent pre-expansion to 90.27 percent postexpansion in expansion states or a 1.94 percent increase. We observe spillovers to Medicare, although this finding is sensitive to specification., Conclusions: This study provides evidence on the impact of ACA-Medicaid expansion on accepted forms of payment for specialty mental health care treatment. Findings suggest that expansion increases availability of providers who deliver valuable care for enrollees with severe mental illness. These findings may help policy makers reflecting on the future directions of the US health care delivery system., (© Health Research and Educational Trust.)

Objective: To quantify the effects of the Affordable Care Act Medicaid expansion on prescriptions for effective breast cancer hormonal therapies (tamoxifen and aromatase inhibitors) among Medicaid enrollees., Data Source/study Setting: Medicaid State Drug Utilization Database (SDUD) 2011-2018, comprising the universe of outpatient prescription medications covered under the Medicaid program., Study Design: Differences-in-differences and event-study linear models compare population rates of tamoxifen and aromatase inhibitor (anastrozole, exemestane, and letrozole) use in expansion and nonexpansion states, controlling for population characteristics, state, and time., Principal Findings: Relative to nonexpansion states, Medicaid-financed hormonal therapy prescriptions increased by 27.2 per 100 000 nonelderly women in a state. This implies a 28.8 percent increase from the pre-expansion mean of 94.2 per 100 000 nonelderly women in expansion states. The event-study model reveals no evidence of differential pretrends in expansion and nonexpansion states and suggests use grew to 40 or more prescriptions per 100 000 nonelderly women 3-5 years postexpansion., Conclusions: Medicaid expansion may have had a meaningful impact on the ability of lower-income women to access effective hormonal therapies used to treat breast cancer., (© Health Research and Educational Trust.)

Objective: To estimate dementia's incremental cost to the traditional Medicare program., Data Sources: Health and Retirement Study (HRS) survey-linked Medicare part A and B claims from 1991 to 2012., Study Design: We compared Medicare expenditures for 60 months following a claims-based dementia diagnosis to those for a randomly selected, matched comparison group., Data Collection/extraction Methods: We used a cost estimator that accounts for differential survival between individuals with and without dementia and decomposes incremental costs into survival and cost intensity components., Principal Findings: Dementia's five-year incremental cost to the traditional Medicare program is approximately $15 700 per patient, nearly half of which is incurred in the first year after diagnosis. Shorter survival with dementia mitigates the incremental cost by about $2650. Increased costs for individuals with dementia were driven by more intensive use of Medicare part A covered services. The incremental cost of dementia was about $7850 higher for females than for males because of sex-specific differential mortality associated with dementia., Conclusions: Dementia's cost to the traditional Medicare program is significant. Interventions that target early identification of dementia and preventable inpatient and post-acute care services could produce substantial savings., (© Health Research and Educational Trust.)

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., (© 2018 The Authors. Health Services Research published by Wiley Periodicals, Inc. on behalf of Health Research and Educational Trust.)

Objective: The Affordable Care Act (ACA) introduced reforms to mitigate adverse selection into and within the individual insurance market. We examined the traits and predicted medical spending of enrollees in California post-ACA., Data Sources: Survey of 2,103 enrollees in individual market plans, on- and off-exchange, in 2014., Study Design: We compared actual versus potential participants using data from the 2014 California Health Interview Survey on respondents who were individually insured or uninsured. We predicted annual medical spending for each group using age, sex, self-rated health, body mass index, smoking status, and income., Principal Findings: Average predicted spending was similar for actual ($3,377, 95 percent CI [$3,280-$3,474]) and potential participants ($3,257 [$3,060-$3,454]); however, some vulnerable subgroups were underrepresented. On- versus off-exchange enrollees differed in sociodemographic and health traits with modest differences in spending ($3,448 [$3,330-$3,565] vs. $3,175 [$3,012-$3,338])., Conclusions: We did not find evidence of selection into the overall insurance pool in 2014; however, differences by exchange status reflect the importance of including off-exchange enrollees in analyses and the pool for risk adjustment. California's post-ACA individual market has been a relative success, highlighting the importance of state policies and outreach efforts to encourage participation in the market., (© Health Research and Educational Trust.)

Objective: To evaluate the effect of Medicaid coverage on dental care outcomes, a major health concern for low-income populations., Data Sources: Primary and secondary data on health care use and outcomes for participants in Oregon's 2008 Medicaid lottery., Study Design: We used the lottery's random selection to gauge the causal effects of Medicaid on dental care needs, medication, and emergency department visits for dental care., Data Collection: Data were collected for lottery participants over 2 years, including mail surveys (N = 23,777) and in-person questionnaires (N = 12,229). Emergency department (ED) records were matched to lottery participants in Portland (N = 24,646)., Principal Findings: Medicaid coverage significantly reduced the share of respondents who reported needing dental care (-9.8 percentage points, p < .001) or having unmet dental care needs (-13.5 percentage points, p < 0.001). Medicaid doubled the share visiting the ED for dental care (+2.6 percentage points, p = .003) and the use of anti-infective medications often prescribed for dental care, but it had no detectable effect on uncovered dental care or out-of-pocket spending., Conclusions: Expansion of Medicaid covering emergency dental care substantially reduced unmet need for dental care, increasing ED dental visits and medication use, while not changing patient use of uncovered dental services., (© Health Research and Educational Trust.)

Objective: Examine the ACA Medicaid expansion effects on Medicaid take-up and private coverage through 2015 and coverage disparities by age, race/ethnicity, and gender., Data Sources: 2011-2015 American Community Survey for 3,137,989 low-educated adults aged 19-64 years., Study Design: Difference-in-differences regressions accounting for national coverage trends and state fixed effects., Principal Findings: Expansion effects doubled in 2015 among low-educated adults, with a nearly 8 percentage-point increase in Medicaid take-up and 6 percentage-point decline in uninsured rate. Significant coverage gains were observed across virtually all examined groups by age, gender, and race/ethnicity. Take-up and insurance declines were strongest among younger adults and were generally close by gender and race/ethnicity. Despite the increased take-up however, coverage disparities remained sizeable, especially for young adults and Hispanics who had declining but still high uninsured rates in 2015. There was some evidence of private coverage crowd-out in certain subgroups, particularly among young adults aged 19-26 years and women, including in both individually purchased and employer-sponsored coverage., Conclusions: The ACA Medicaid expansions have continued to increase coverage in 2015 across the entire population of low-educated adults and have reduced age disparities in coverage. However, there is still a need for interventions that target eligible young and Hispanic adults., (© Health Research and Educational Trust.)

Objective: We discuss how to interpret coefficients from logit models, focusing on the importance of the standard deviation (σ) of the error term to that interpretation., Study Design: We show how odds ratios are computed, how they depend on the standard deviation (σ) of the error term, and their sensitivity to different model specifications. We also discuss alternatives to odds ratios., Principal Findings: There is no single odds ratio; instead, any estimated odds ratio is conditional on the data and the model specification. Odds ratios should not be compared across different studies using different samples from different populations. Nor should they be compared across models with different sets of explanatory variables., Conclusions: To communicate information regarding the effect of explanatory variables on binary {0,1} dependent variables, average marginal effects are generally preferable to odds ratios, unless the data are from a case-control study., (© Health Research and Educational Trust.)

Objective: To examine the effects of distance to dentists and dentist supply on dental services use among children with Medicaid coverage in Iowa., Data Source: Iowa Medicaid claims for enrolled children between 2000 and 2009., Study Design: The study sample included 41,554 children (providing 158,942 child-year observations) who were born in Iowa between 2000 and 2006 and enrolled from birth in the Iowa Medicaid program. Children were followed through 2009. We used logistic regression to simultaneously examine the effects of distance (miles to nearest dentist) and county-level dentist supply on a broad range of dental services controlling for key confounders. Additional models only used within-child variation over time to remove unobservable time-invariant confounders., Principal Findings: Distance was related to lower utilization of comprehensive dental exams (2 percent lower odds per 1 mile increase in distance), an effect that also held in models using within-child variation only. Dentist supply was positively related to comprehensive exams and other preventive services and negatively related to major dental treatments; however, these associations became smaller and insignificant when examining within-child changes except for other preventive services., Conclusions: Longer distance to dentists is a barrier for use of comprehensive dental exams, conditional on dentist supply., (© Health Research and Educational Trust.)

Objective: To evaluate the comparative safety of laparoscopic and open colectomy across surgeons varying in experience with laparoscopy., Data Sources: National Medicare data (2008-2010) for beneficiaries undergoing laparoscopic or open colectomy., Study Design: Using instrumental variable methods to address selection bias, we evaluated outcomes of laparoscopic and open colectomy. Our instrument was the regional use of laparoscopy in the year prior to a patient's operation. We then evaluated outcomes stratified by surgeons' annual volume of laparoscopic colectomy., Principal Findings: Laparoscopic colectomy was associated with lower mortality (OR: 0.75, 95 percent CI: 0.70-0.78) and fewer complications than open surgery (OR: 0.82, 95 percent CI: 0.79-0.85). Increasing surgeon volume was associated with better outcomes for both procedures, but the relationship was stronger for laparoscopy. The comparative safety depended on surgeon volume. High-volume surgeons had 40 percent lower mortality (OR: 0.60, 95 percent CI: 0.55-0.65) and 30 percent fewer complications (OR: 0.70, 95 percent CI: 0.67-0.74) with laparoscopy. Conversely, low-volume surgeons had 7 percent higher mortality (OR: 1.07, 95 percent CI: 1.02-1.13) and 18 percent more complications (OR: 1.18, 95 percent CI: 1.12-1.24) with laparoscopy., Conclusions: This population-based study demonstrates that the comparative safety of laparoscopic and open colectomy is influenced by surgeon volume. Laparoscopic colectomy is only safer for patients whose surgeons have sufficient experience., (© Health Research and Educational Trust.)

Objective: To determine whether the observed differences in the risk-adjusted rehospitalization rates across skilled nursing facilities (SNFs) reflect true differences or merely differences in patient severity., Settings: Elderly Medicare beneficiaries newly admitted to an SNF following hospitalization., Study Design: We used 2009-2012 Medicare data to calculate SNFs' risk-adjusted rehospitalization rate. We then estimated the effect of these rehospitalization rates on the rehospitalization of incident patients in 2013, using an instrumental variable (IV) method and controlling for patient's demographic and clinical characteristics and residential zip code fixed effects. We used the number of empty beds in a patient's proximate SNFs during hospital discharge to create the IV., Principal Findings: The risk-adjusted rehospitalization rate varies widely; about one-quarter of the SNFs have a rehospitalization rate lower than 17 percent, and for one-quarter, it is higher than 23 percent. All the IV models result in a robust finding that an increase in a SNF's rehospitalization rate of 1 percentage point over the period 2009-2012 leads to an increase in a patient's likelihood of rehospitalization by 0.8 percentage points in 2013., Conclusions: Treatment in SNFs with historically low rehospitalization causally reduces a patient's likelihood of rehospitalization. Observed differences in rehospitalization rates reflect true differences and are not an artifact of selection., (© Health Research and Educational Trust.)

Objective: To examine the impact of a 2007 redesign of West Virginia's Medicaid program, which included an incentive and "nudging" scheme intended to encourage better health care behaviors and reduce Emergency Department (ED) visits., Data Sources: West Virginia Medicaid enrollment and claims data from 2005 to 2010., Study Design: We utilized a "differences in differences" technique with individual and time fixed effects to assess the impact of redesign on ED visits. Starting in 2007, categorically eligible Medicaid beneficiaries were moved from traditional Medicaid to the new Mountain Health Choices (MHC) Program on a rolling basis, approximating a natural experiment. Members chose between a Basic plan, which was less generous than traditional Medicaid, or an Enhanced plan, which was more generous but required additional enrollment steps., Data Collection: Data were obtained from the West Virginia Bureau for Medical Services., Principal Findings: We found that contrary to intentions, the MHC program increased ED visits. Those who selected or defaulted into the Basic plan experienced increased overall and preventable ED visits, while those who selected the Enhanced plan experienced a slight reduction in preventable ED visits; the net effect was an increase in ED visits, as most individuals enrolled in the Basic plan., (© Health Research and Educational Trust.)

Objective: To determine how access to percutaneous coronary intervention (PCI) is distributed across demographics., Data Sources: Secondary data from the 2011 American Hospital Association (AHA) survey data combined with 2010 Census., Study Design: We calculated prehospital times from 32,370 ZIP codes to the nearest PCI center. We used a multivariate logit model to determine the odds of untimely access by the ZIP code's concentration of vulnerable populations., Data Collection: We used ZIP code-level data on community characteristics from the 2010 Census and supplemented it with 2011 AHA survey data on service-line availability of PCI for responding hospitals., Principal Findings: For approximately 306 million Americans, the median prehospital time to the nearest PCI center is 33 minutes. While 84 percent of Americans live within one hour of a PCI center, the odds of untimely access are higher in low-income (OR: 3.00; 95 percent CI: 2.39, 3.77), rural (8.10; 95 percent CI: 6.84, 9.59), and highly Hispanic communities (2.55; 95 percent CI: 1.86, 3.49)., Conclusions: While the majority of Americans live within 60 minutes of a PCI center, rural, low-income, and highly Hispanic communities have worse PCI access. This may translate into worse outcomes for patients with acute myocardial infarction., (© Health Research and Educational Trust.)

Objectives: To compare concordance of survey reports of health service use versus claims data between self respondents and spousal and nonspousal relative proxies., Data Sources: 1995-2010 data from the Survey on Assets and Health Dynamics among the Oldest Old and 1993-2010 Medicare claims for 3,229 individuals (13,488 person-years)., Study Design: Regression models with individual fixed effects were estimated for discordance of any hospitalizations and outpatient surgery and for the numbers of under- and over-reported physician visits., Principal Findings: Spousal proxies were similar to self respondents on discordance. Nonspousal proxies, particularly daughters/daughters-in-law and sons/sons-in-law, had less discordance, mainly due to reduced under-reporting., Conclusions: Survey reports of health services use from nonspousal relatives are more consistent with Medicare claims than spousal proxies and self respondents., (© Health Research and Educational Trust.)

Objective: Rank county health using a Bayesian factor analysis model., Data Sources: Secondary county data from the National Center for Health Statistics (through 2007) and Behavioral Risk Factor Surveillance System (through 2009)., Study Design: Our model builds on the existing county health rankings (CHRs) by using data-derived weights to compute ranks from mortality and morbidity variables, and by quantifying uncertainty based on population, spatial correlation, and missing data. We apply our model to Wisconsin, which has comprehensive data, and Texas, which has substantial missing information., Data Collection Methods: The data were downloaded from www.countyhealthrankings.org., Principal Findings: Our estimated rankings are more similar to the CHRs for Wisconsin than Texas, as the data-derived factor weights are closer to the assigned weights for Wisconsin. The correlations between the CHRs and our ranks are 0.89 for Wisconsin and 0.65 for Texas. Uncertainty is especially severe for Texas given the state's substantial missing data., Conclusions: The reliability of comprehensive CHRs varies from state to state. We advise focusing on the counties that remain among the least healthy after incorporating alternate weighting methods and accounting for uncertainty. Our results also highlight the need for broader geographic coverage in health data., (© Health Research and Educational Trust.)

Objective: To examine the sources of family income dynamics leading to movement into and out of Medicaid expansion and subsidy eligibility under the Affordable Care Act., Data Source: Survey of Income and Program Participation (SIPP): 1996, 2001, 2004, 2008 panels., Study Design: Considering four broad subsidy eligibility categories for monthly Modified Adjusted Gross Income (MAGI) (<138 percent of the Federal Poverty Level [FPL], 138-250 percent FPL, 250-400 percent FPL, and >400 percent FPL), I use duration analysis to examine determinants of movements between categories over the course of a year., Data Collection/extraction: Using detailed monthly data, I determine the members of tax-filing units and calculate an approximation of MAGI at the monthly level. The analysis sample is adults ages 22-64 years., Principal Findings: Incomes are highly variable within a year, particularly at the lower end of the income distribution. Employment transitions, including transitions not involving a period of nonemployment, and family structure changes strongly predict sufficient income volatility to trigger a change in subsidy category., Conclusions: Income volatility arising from employment and family structure changes is likely to trigger changes in subsidy eligibility within the year, but the sources and effects of the volatility differ substantially depending on the individual's position in the income distribution., (© Health Research and Educational Trust.)

Objective: We analyze whether decreased emergency department (ED) access results in adverse patient outcomes or changes in the patient health profile for patients with acute myocardial infarction (AMI)., Data: We merge Medicare claims, American Hospital Association annual surveys, Medicare hospital cost reports, and location information for 1995-2005., Study Design: We define four ED access change categories and estimate a ZIP Code fixed-effects regression models on the following AMI outcomes: mortality rates, age, and probability of percutaneous transluminal coronary angioplasty (PTCA) on day of admission., Principal Findings: We find a small increase in 30-day to 1-year mortality rates among patients in communities that experience a <10-minute increase in driving time. Among patients in communities with >30-minute increases, we find a substantial increase in long-term mortality rates, a shift to younger ages (suggesting that older patients die en route), and a higher probability of immediate PTCA. Most of the adverse effects disappear after the transition years., Conclusions: Deterioration in geographic access to ED affects a small segment of the population, and most adverse effects are transitory. Policy planners can minimize the adverse effects by providing assistance to ensure adequate capacity of remaining EDs, and facilitating the realignment of health care resources during the critical transition periods., (© Health Research and Educational Trust.)

Background: Many states have passed legislation mandating that health plans provide direct access to obstetricians/gynecologists (hereinafter "ob/gyns") for women, limiting the ability of plans to require referrals or otherwise restrict access. One benefit of these laws may be improved preventive screening rates, but no literature has examined the relationship between ob/gyn direct access laws and use of breast cancer and cervical cancer screening., Data and Methods: We use repeated cross-sections of privately insured women age 18-64 (Pap test) and 40-64 (mammography) from the Behavioral Risk Factor Surveillance System for 1996-2000, linked to data on the presence of ob/gyn direct access laws by state. Outcome measures are receipt of mammography and receipt of a Pap test within the past 2 years. Regression analyses are used to assess the relationship between the presence of ob/gyn direct access laws and screening, adjusting for a range of individual characteristics, fixed state characteristics, and time trends., Results: We find no statistically significant relationships between the presence of an ob/gyn direct access law and receipt of either mammography or Pap test screening. We explore a range of alternate specifications and find none that yield clear evidence of a relationship., Conclusions: Laws requiring direct access to ob/gyns are not associated with large or consistent measurable impacts on use of cancer screening.