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Numerous states implemented laws to protect emergency patients from surprise out‐of‐network medical bills. We investigated the effects of the state laws on emergency clinician reimbursements, charges, network participation, and potential surprise billing episodes. We did not find consistent evidence of effects on prices or charges. However, the state laws resulted in increased network participation and a reduction in potential surprise billing episodes. Our results suggest that the federal No Surprises Act, which is similar to many of the state laws, is unlikely to lead to price increases, but may benefit patients through increased provider network participation and alignment. [ABSTRACT FROM AUTHOR]

Objective: To examine rural–urban disparities in substance use disorder treatment access and continuation. Data Sources and Study Setting: We analyzed a 2016–2018 U.S. national secondary dataset of commercial insurance claims. Study Design: This cross‐sectional study examined individuals with a new episode of opioid, alcohol, or other drug use disorders. Treatment initiation and engagement rates, and rates of using out‐of‐network providers for these services, were compared between rural and urban patients. Data Collection: We included individuals 18–64 years old with continuous employer‐sponsored insurance. Principal Findings: Patients in rural settings experienced lower treatment initiation rates for alcohol (36.6% vs. 38.0%, p < 0.001), opioid (41.2% vs. 44.2%, p < 0.001), and other drug (37.7% vs. 40.1%, p < 0.001) use disorders, relative to those in urban areas. Similarly, rural patients had lower treatment engagement rates for alcohol (15.1% vs. 17.3%, p < 0.001), opioid (21.0% vs. 22.6%, p < 0.001), and other drug (15.5% vs. 17.5%, p < 0.001) use disorders. Rural patients had higher out‐of‐network rates for treatment initiation for other drug use disorders (20.4% vs. 17.2%, p < 0.001), and for treatment engagement for alcohol (27.6% vs. 25.2%, p = 0.006) and other drug (36.1% vs. 31.1%, p < 0.001) use disorders. Conclusions: These findings indicate that individuals with substance use disorders in rural areas have lower rates of initial and ongoing treatment, and are more likely to seek care out‐of‐network. [ABSTRACT FROM AUTHOR]

Background: Advance care planning (ACP), or the consideration and communication of care preferences for the end-of-life (EOL), is a critical process for improving quality of care for patients with advanced cancer. The incorporation of billed service codes for ACP allows for new inquiries on the association between systematic ACP and improved EOL outcomes. Objective: Using the IBM MarketScan® Database, we conducted a retrospective medical claims analysis for patients with an advanced cancer diagnosis and referral to hospice between January 2016 and December 2017. We evaluated the association between billed ACP services and EOL hospital admissions in the final 30 days of life. Design: This is a cross-sectional retrospective cohort study. Participants: A total of 3,705 patients met the study criteria. Main Measures: ACP was measured via the presence of a billed ACP encounter (codes 99497 and 99498) prior to the last 30 days of life; hospital admissions included a dichotomous indicator for inpatient admission in the final 30 days of life. Key Results: Controlling for key covariates, patients who received billed ACP were less likely to experience inpatient hospital admissions in the final 30 days of life compared to those not receiving billed ACP (OR: 0.34; p < 0.001). Conclusion: The receipt of a billed ACP encounter is associated with reduced EOL hospital admissions in a population of patients with advanced cancer on hospice care. Strategies for consistent, anticipatory delivery of billable ACP services prior to hospice referral may prevent potentially undesired late-life hospital admissions. [ABSTRACT FROM AUTHOR]

Stroke patients appear to have similar outcomes regardless of which type of insurance plan they have. Researchers compared outcomes in 402 stroke patients covered by an HMO and 408 covered by a fee-for-service plan (Medicare). Both groups had a similar risk of dying, but the HMO patients were more likely to be discharged to a nursing home and less likely to be discharged to a rehabilitation facility. The federal government has been encouraging many Medicare recipients to enroll in HMO plans in order to cut costs., Context.--Increasing numbers of Medicare beneficiaries have been enrolling in health maintenance organizations (HMOs) because HMO participation reduces out-of-pocket expenses, and the federal government views HMOs as a way to contain Medicare costs. However, results comparing outcomes and quality of care in HMOs vs fee-for-service (FFS) have been mixed, and outcomes after stroke have not been adequately assessed. Objective.--To compare discharge destinations and survival rates following stroke in Medicare HMOs with similar FFS settings. Design.--An observational study for 2 groups evaluating stroke patients&apos; discharge destinations and survival times from the date of hospital admission. Setting.--A total of 19 HMOs were selected from 12 states. The FFS sample was drawn from the same geographic areas. Patients.--The sample included 402 HMO patients from 71 hospitals and 408 FFS patients from 60 hospitals. Process and Outcome Measures.--Data were abstracted from medical records on demographics, clinical characteristics of stroke, comorbid illnesses, and discharge destinations following hospitalization. Data on survival were obtained from Medicare files and included 25 to 37 months of follow-up (median, 30.4 months, HMO; 31.1 months, FFS) from the date of hospital admission. Results.--There were 109 patients who died during the hospitalization (49 HMO, 12.2%; 60 FFS, 14.7%), and a total of 410 patients had died by the end of follow-up (191 HMO, 47.5%; 219 FFS, 53.7%). Approximately one fourth of both groups had do-not-resuscitate orders (HMO, 25.4%; FFS, 27.9%; P=.68). After controlling for age, marital status, and characteristics of dependency at discharge, HMO patients were more likely than FFS patients to be sent to nursing homes (HMO, 41.8%; FFS, 27.9%; P=.001) and less likely to be discharged to rehabilitation hospitals or units (HMO, 16.2%; FFS, 23.4%; P=.03). At follow-up, no significant differences in relative risk of dying were found between HMO and FFS groups (relative risk, 0.96; 95% confidence interval, 0.73-1.26; P=.77). Conclusions.-Patients in Medicare HMOs who experience strokes are more likely to be discharged to nursing homes and less likely to go to rehabilitation facilities following the acute event. However, they have similar survival patterns compared with comparable patients in FFS settings after adjusting for other factors.

Health maintenance organizations (HMOs) appear less likely to refer elderly Medicare patients to specialists or to recommend follow-up treatment than fee-for-service health organizations. A total of 6,476 elderly HMO Medicare patients were compared with 6,381 elderly Medicare patients in fee-for-service health plans. Both sets of patients had either chest pains or joint pains. HMO patients with joint pains were more likely to see a doctor and have medication prescribed than those in fee-for-service plans. However, fee-for-service patients with chest pain were more likely to see a physician. Overall, fee-for-service Medicare patients were more likely than HMO Medicare patients to see specialists for treatment, have recommended follow-up treatments and have their progress monitored. Nonetheless, the outcome of care was similar for both groups.

Objective Study Design Data Source and Analytic Sample Principal Findings Conclusions What is known on this topic What this study adds To examine the effects of New York's surprise billing regulations on price changes by emergency ground ambulance service providers.We exploited a natural experiment using a difference‐in‐differences design with randomization inference (RI) to examine the effects of New York state regulations on the prices of emergency ground ambulances, analyzing 2012–2019 commercial claims data. In March 2015, New York implemented a law protecting patients from surprise out‐of‐network (OON) balance bills, including ground ambulance services. New York's policy tied OON ground ambulance reimbursements to usual, customary, and reasonable rates that typically reflect charges. The control group consisted of similar states that never enacted surprise billing laws. Although self‐funded plans are exempted from state laws, we also examined for spillover effects on self‐funded plans.Multi‐payer national commercial plan claims data were used. The study sample was selected by isolating claims involving an emergency ground ambulance activation code.The event study findings indicated that New York's law led to a continuous increase in prices, relative to controls. The law's implementation was associated with an overall emergency ground ambulance price increase of 13 percentage points (RI p‐value: 0.07). We observed a 21‐percentage‐point increase in in‐network prices (RI p‐value: 0.07) and a 19‐percentage‐point increase in OON prices (RI p‐value: 0.07), relative to controls, for fully insured health plans. Similar changes in overall prices and in in‐network prices were observed in self‐insured plans. Last, our study did not find statistically significant evidence of changes in out‐of‐pocket cost‐sharing amounts under New York's regulation.Balance billing laws based on charges can lead to price increases for emergency ground ambulance services. Legislation intended to inoculate patients from these surprise billings for ground ambulance transportation may have unintended consequences for costs of care. Emergency ground ambulances are a major source of surprise billing. The federal No Surprises Act of 2020 excluded emergency ground ambulance services. Some states have regulations that prohibit out‐of‐network balance bills for ground ambulance services. The study provides the first empirical evidence on the potential impacts of regulations on price changes among emergency ground ambulance providers. The study offers evidence of state policies' effects on fully insured plans and potential spillover effects on self‐funded plans. Experiences from New York's state ambulance out‐of‐network billing regulation indicate that tying reimbursement policies to charges may have the unintended consequences of increasing health care costs. [ABSTRACT FROM AUTHOR]

In discussing Waller's paper, we build on his review of medical conditions and the risk of motor vehicle accidents (MVAs) using principles derived from geriatrics, gerontology, and health services research. Three approaches are suggested. The medical model uses discrete diseases as risk factors, but despite its utility and appeal, this model does not sufficiently characterize health and functional status to be the sole approach, and future investigative efforts should at least consider severity of illness concepts. The functional status model emphasizes a functional and physiological approach to health status, but despite its successful application in geriatric assessment and its investigative promise, functional status can be difficult to measure and has not been validated in relation to MVA risk. Finally we consider a behavioral model and within that framework discuss the relation of depressive and other emotional illnesses as well as social vitality to driving patterns and MVA occurrence.

As a strategy for containing medical costs, the federal government has developed a program in which Medicare recipients can join health maintenance organizations (HMOs). In 1982, the option was first offered to persons on Medicare and there are now about one million enrollees at over 100 different HMOs. For each Medicare enrollee, the federal government makes a monthly payment to the HMO, which provides comprehensive health care and assumes the entire financial risk for the patient's health care. The goal of this new prepaid system is to reduce total medical costs without any decrease in the quality of care. But it has been suggested that the HMO approach may be less effective for the elderly patient than a younger individual, because HMOs limit costs by providing as many services as possible on an outpatient or ambulatory basis, to reduce the number of hospitalizations. Older persons with chronic illnesses may require extensive or frequent services that can be provided outside of the hospital, but their physical disabilities and transportation problems may make this difficult or impossible. A study to compare routine, fee-for-service (FFS) care with HMO care obtained by Medicare patients is reported here. Outpatient medical records were examined for purposes of the comparison; 777 FFS and 813 HMO records were included. The HMOs were broken down into two types, staff/group and independent practice associations. The analysis showed that enrollees in the staff/group HMOs were more likely to receive the recommended preventive and health maintenance services than Medicare patients using FFS; these services included mammography, pelvic examination, rectal examination, and fecal occult blood testing. (Consumer Summary produced by Reliance Medical Information, Inc.)

OBJECTIVES: To determine whether enough primary care providers are in close proximity to where dual-eligible beneficiaries live to provide the capacity needed for integrated care models. STUDY DESIGN: Secondary data analysis using dualeligible enrollment data and health care workforce data. METHODS: We determined the density of dual-eligible beneficiaries per 1000 population in 2017 for each of 3142 US counties. County-level supply of primary care physicians (PCPs), primary care nurse practitioners, and physician assistants was determined. RESULTS: One-third of the 791 counties with the highest density of dual-eligible beneficiaries had PCP shortages. Counties with the highest density of dual-eligible beneficiaries and the fewest primary care clinicians of any type were concentrated in Southeastern states. These areas also had some of the highest COVID-19 outbreaks within their states. CONCLUSIONS: States in the Southeastern region of the United States with some of the most restrictive scope-ofpractice laws have an inadequate supply of primary care providers to serve a high concentration of dual-eligible beneficiaries. The fragmented care of the dually eligible population leads to extremely high costs, prompting policy makers to consider integrated delivery models that emphasize primary care. However, primary care workforce shortages will be an enduring challenge without scope-ofpractice reforms. [ABSTRACT FROM AUTHOR]

Increasing interprofessional practice is seen as a path to improved quality, decreased cost, and enhanced patient experience. However, little is known about how context shapes interprofessional work and how interventions should be crafted to account for a specific setting of interprofessional practice. To better understand, how the work of interprofessional practice differs across patient care settings we sought to understand the social processes found in varying work contexts to better understand how care is provided. A case study design was used in this study to yield a picture of patient care across three different settings. Qualitative analysis of teams from three healthcare settings (rehabilitation, acute care, and code team) was conducted, through the use of ten in-depth semi-structured interviews. Interview data from each participant were analyzed via an inductive content analysis approach based upon theories of work and teams from organisational science, a framework for interprofessional practice, and competencies for interprofessional education. The work processes of interprofessional practice varied across settings. Information exchange was more physician-centric and decision-making was more physician dominant in the non-rehabilitation settings. Work was described as concurrent only for the code team. Goal setting varied by setting and interpersonal relationships were only mentioned as important in the rehabilitation setting. The differences observed across settings identify some insights into how context shapes the process of interprofessional collaboration and some research questions that need further study. [ABSTRACT FROM PUBLISHER]