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Matta S, Chatterjee P, Venkataramani AS. Changes in Health Care Workers' Economic Outcomes Following Medicaid Expansion. JAMA 2024; 331:687-695. [PMID: 38411645 PMCID: PMC10900969 DOI: 10.1001/jama.2023.27014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/28/2024]
Abstract
Importance The extent to which changes in health sector finances impact economic outcomes among health care workers, especially lower-income workers, is not well known. Objective To assess the association between state adoption of the Affordable Care Act's Medicaid expansion-which led to substantial improvements in health care organization finances-and health care workers' annual incomes and benefits, and whether these associations varied across low- and high-wage occupations. Design, Setting, and Participants Difference-in-differences analysis to assess differential changes in health care workers' economic outcomes before and after Medicaid expansion among workers in 30 states that expanded Medicaid relative to workers in 16 states that did not, by examining US individuals aged 18 through 65 years employed in the health care industry surveyed in the 2010-2019 American Community Surveys. Exposure Time-varying state-level adoption of Medicaid expansion. Main Outcomes and Measures Primary outcome was annual earned income; secondary outcomes included receipt of employer-sponsored health insurance, Medicaid, and Supplemental Nutrition Assistance Program benefits. Results The sample included 1 322 263 health care workers from 2010-2019. Health care workers in expansion states were similar to those in nonexpansion states in age, sex, and educational attainment, but those in expansion states were less likely to identify as non-Hispanic Black. Medicaid expansion was associated with a 2.16% increase in annual incomes (95% CI, 0.66%-3.65%; P = .005). This effect was driven by significant increases in annual incomes among the top 2 highest-earning quintiles (β coefficient, 2.91%-3.72%), which includes registered nurses, physicians, and executives. Health care workers in lower-earning quintiles did not experience any significant changes. Medicaid expansion was associated with a 3.15 percentage point increase in the likelihood that a health care worker received Medicaid benefits (95% CI, 2.46 to 3.84; P < .001), with the largest increases among the 2 lowest-earning quintiles, which includes health aides, orderlies, and sanitation workers. There were significant decreases in employer-sponsored health insurance and increases in SNAP following Medicaid expansion. Conclusion and Relevance Medicaid expansion was associated with increases in compensation for health care workers, but only among the highest earners. These findings suggest that improvements in health care sector finances may increase economic inequality among health care workers, with implications for worker health and well-being.
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Affiliation(s)
- Sasmira Matta
- Department of Health Care Management, Wharton School, University of Pennsylvania, Philadelphia
- Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia
| | - Paula Chatterjee
- Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia
- Division of General Internal Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia
| | - Atheendar S Venkataramani
- Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia
- Department of Medical Ethics and Health Policy, Perelman School of Medicine, University of Pennsylvania, Philadelphia
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Wahid N, Lee J, Rosenblatt R, Kaplan A, Tipirneni R, Fortune BE, Safford M, Brown RS. Affordable Care Act Medicaid expansion associated with increased liver transplant waitlist access without worsening mortality. Liver Transpl 2024; 30:20-29. [PMID: 37486623 DOI: 10.1097/lvt.0000000000000221] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/02/2023] [Accepted: 07/03/2023] [Indexed: 07/25/2023]
Abstract
It is unclear what impact Affordable Care Act (ACA) Medicaid expansion has had on the liver transplantation (LT) waitlist. We aimed to assess associations between ACA Medicaid expansion and LT waitlist outcomes. The United Network for Organ Sharing Standard Transplant Analysis and Research (UNOS STAR) database was queried for patients listed for LT between January 1, 2009, and December 31, 2018. Our primary outcome was waitlist mortality and our secondary outcomes included Medicaid use on the LT waitlist and transplant rate. States were divided into groups based on their expansion status and the study period was divided into 2 time intervals-pre-expansion and post-expansion. Difference-in-difference (DiD) models were created to assess the impacts of expansion on each of the outcomes and for racial/ethnic and sex groups. In total, 56,414 patients from expansion states and 32,447 patients from nonexpansion states were included. Three-year waitlist mortality decreased at a similar rate in both cohorts [DiD estimate: 0.1, (95% CI, -1.1, -1.4), p = 0.838], but Medicaid use increased [DiD estimate: +7.7, (95% CI, 6.7, 8.7), p < 0.001] to a greater degree in expansion states after expansion than nonexpansion states. Between the 2 time intervals, Medicaid use on the LT waitlist increased from 19.4% to 26.1% in expansion states but decreased from 13.4% to 12.1% in nonexpansion states. In patients on Medicaid, there was a slight increase in the 3-year transplant rate associated with Medicaid expansion [DiD estimate +5.0, (95% CI, 1.8, 8.3), p = 0.002], which may in part be explained by differences in patient characteristics. Medicaid expansion was associated with increased Medicaid use on the LT waitlist without worsening overall waitlist mortality or transplant rate, suggesting that lenient and widespread public health insurance may increase access to the LT waitlist without adversely affecting outcomes.
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Affiliation(s)
- Nabeel Wahid
- Department of Medicine, Division of Gastroenterology and Hepatology, Northwestern Medicine, Chicago, Illinois
| | - Jihui Lee
- Department of Psychiatry, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Russell Rosenblatt
- Department of Medicine, Division of Gastroenterology and Hepatology, Weill Cornell Medicine, New York-Presbyterian Hospital, New York, New York
| | - Alyson Kaplan
- Department of Medicine, Division of Gastroenterology and Hepatology, Weill Cornell Medicine, New York-Presbyterian Hospital, New York, New York
| | - Renuka Tipirneni
- Department of Internal Medicine, Division of General Medicine, Institute for Healthcare Policy & Innovation, University of Michigan, Ann Arbor, Michigan
| | - Brett E Fortune
- Department of Medicine, Division of Hepatology, Montefiore Medical Center/Albert Einstein College of Medicine, Bronx, New York
| | - Monika Safford
- Department of Medicine, Division of General Internal Medicine, Weill Cornell Medicine, New York-Presbyterian Hospital, New York, New York
| | - Robert S Brown
- Department of Medicine, Division of Gastroenterology and Hepatology, Weill Cornell Medicine, New York-Presbyterian Hospital, New York, New York
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Wang MC, Bangaru S, Zhou K. Care for Vulnerable Populations with Chronic Liver Disease: A Safety-Net Perspective. Healthcare (Basel) 2023; 11:2725. [PMID: 37893800 PMCID: PMC10606794 DOI: 10.3390/healthcare11202725] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2023] [Revised: 10/07/2023] [Accepted: 10/10/2023] [Indexed: 10/29/2023] Open
Abstract
Safety-net hospitals (SNHs) and facilities are the cornerstone of healthcare services for the medically underserved. The burden of chronic liver disease-including end-stage manifestations of cirrhosis and liver cancer-is high and rising among populations living in poverty who primarily seek and receive care in safety-net settings. For many reasons related to social determinants of health, these individuals often present with delayed diagnoses and disease presentations, resulting in higher liver-related mortality. With recent state-based policy changes such as Medicaid expansion that impact access to insurance and critical health services, an overview of the body of literature on SNH care for chronic liver disease is timely and informative for the liver disease community. In this narrative review, we discuss controversies in the definition of a SNH and summarize the known disparities in the cascade of the care and management of common liver-related conditions: (1) steatotic liver disease, (2) liver cancer, (3) chronic viral hepatitis, and (4) cirrhosis and liver transplantation. In addition, we review the specific impact of Medicaid expansion on safety-net systems and liver disease outcomes and highlight effective provider- and system-level interventions. Lastly, we address remaining gaps and challenges to optimizing care for vulnerable populations with chronic liver disease in safety-net settings.
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Affiliation(s)
- Mark C Wang
- Department of Medicine, Keck School of Medicine, University of Southern California, Los Angeles, CA 90033, USA
| | - Saroja Bangaru
- Department of Medicine, Keck School of Medicine, University of Southern California, Los Angeles, CA 90033, USA
- Los Angeles General Medical Center, Los Angeles, CA 90033, USA
| | - Kali Zhou
- Department of Medicine, Keck School of Medicine, University of Southern California, Los Angeles, CA 90033, USA
- Los Angeles General Medical Center, Los Angeles, CA 90033, USA
- Research Center for Liver Diseases, Keck School of Medicine, University of Southern California, Los Angeles, CA 90033, USA
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Chatterji P, Glenn H, Markowitz S, Montez JK. Affordable Care Act Medicaid expansions and maternal morbidity. HEALTH ECONOMICS 2023; 32:2334-2352. [PMID: 37417880 PMCID: PMC10691745 DOI: 10.1002/hec.4724] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/02/2023] [Revised: 05/18/2023] [Accepted: 06/06/2023] [Indexed: 07/08/2023]
Abstract
In this paper, we test whether the Affordable Care Act Medicaid expansions are associated with maternal morbidity. The ACA expansions may have affected maternal morbidity by increasing pre-conception access to health care, and by improving the quality of delivery care, through enhancing hospitals' financial positions. We use difference-in-difference models in conjunction with event studies. Data come from individual-level birth certificates and state-level hospital discharge data. The results show little evidence that the expansions are associated with overall maternal morbidity or indicators of specific adverse events including eclampsia, ruptured uterus, and unplanned hysterectomy. The results are consistent with prior research showing that the ACA Medicaid expansions are not statistically associated with pre-pregnancy health or maternal health during pregnancy. Our results add to this story and find little evidence of improvements in maternal health upon delivery.
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Rochlin DH, Rizk NM, Flores RL, Matros E, Sheckter CC. The Reality of Commercial Payer-Negotiated Rates in Cleft Lip and Palate Repair. Plast Reconstr Surg 2023; 152:476e-487e. [PMID: 36847669 DOI: 10.1097/prs.0000000000010329] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/01/2023]
Abstract
BACKGROUND Commercial payer-negotiated rates for cleft lip and palate surgery have not been evaluated on a national scale. The aim of this study was to characterize commercial rates for cleft care, both in terms of nationwide variation and in relation to Medicaid rates. METHODS A cross-sectional analysis was performed of 2021 hospital pricing data from Turquoise Health, a data service platform that aggregates hospital price disclosures. The data were queried by CPT code to identify 20 cleft surgical services. Within- and across-hospital ratios were calculated per CPT code to quantify commercial rate variation. Generalized linear models were used to assess the relationship between median commercial rate and facility-level variables and between commercial and Medicaid rates. RESULTS There were 80,710 unique commercial rates from 792 hospitals. Within-hospital ratios for commercial rates ranged from 2.0 to 2.9 and across-hospital ratios ranged from 5.4 to 13.7. Median commercial rates per facility were higher than Medicaid rates for primary cleft lip and palate repair ($5492.20 versus $1739.00), secondary cleft lip and palate repair ($5429.10 versus $1917.00), and cleft rhinoplasty ($6001.00 versus $1917.00; P < 0.001). Lower commercial rates were associated with hospitals that were smaller ( P < 0.001), safety-net ( P < 0.001), and nonprofit ( P < 0.001). Medicaid rate was positively associated with commercial rate ( P < 0.001). CONCLUSIONS Commercial rates for cleft surgical care demonstrated marked variation within and across hospitals, and were lower for small, safety-net, or nonprofit hospitals. Lower Medicaid rates were not associated with higher commercial rates, suggesting that hospitals did not use cost-shifting to compensate for budget shortfalls resulting from poor Medicaid reimbursement.
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Affiliation(s)
- Danielle H Rochlin
- From the Plastic and Reconstructive Surgery Service, Department of Surgery, Memorial Sloan Kettering Cancer Center
| | - Nada M Rizk
- Division of Plastic and Reconstructive Surgery, Stanford University Medical Center
| | - Roberto L Flores
- Hansjörg Wyss Department of Plastic Surgery, New York University Grossman School of Medicine
| | - Evan Matros
- From the Plastic and Reconstructive Surgery Service, Department of Surgery, Memorial Sloan Kettering Cancer Center
| | - Clifford C Sheckter
- Division of Plastic and Reconstructive Surgery, Stanford University Medical Center
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Phillips KA, Marshall DA, Adler L, Figueroa J, Haeder SF, Hamad R, Hernandez I, Moucheraud C, Nikpay S. Ten health policy challenges for the next 10 years. HEALTH AFFAIRS SCHOLAR 2023; 1:qxad010. [PMID: 38756834 PMCID: PMC10986244 DOI: 10.1093/haschl/qxad010] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 04/04/2023] [Accepted: 04/14/2023] [Indexed: 05/18/2024]
Abstract
Health policies and associated research initiatives are constantly evolving and changing. In recent years, there has been a dizzying increase in research on emerging topics such as the implications of changing public and private health payment models, the global impact of pandemics, novel initiatives to tackle the persistence of health inequities, broad efforts to reduce the impact of climate change, the emergence of novel technologies such as whole-genome sequencing and artificial intelligence, and the increase in consumer-directed care. This evolution demands future-thinking research to meet the needs of policymakers in translating science into policy. In this paper, the Health Affairs Scholar editorial team describes "ten health policy challenges for the next 10 years." Each of the ten assertions describes the challenges and steps that can be taken to address those challenges. We focus on issues that are traditionally studied by health services researchers such as cost, access, and quality, but then examine emerging and intersectional topics: equity, income, and justice; technology, pharmaceuticals, markets, and innovation; population health; and global health.
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Affiliation(s)
- Kathryn A Phillips
- UCSF Center for Translational and Policy Research on Precision Medicine (TRANSPERS), University of California, San Francisco, San Francisco, CA 94143, United States
- Department of Clinical Pharmacy, University of California, San Francisco, San Francisco, CA 94143, United States
- Philip R. Lee Institute for Health Policy Studies, University of California, San Francisco, San Francisco, CA 94158, United States
| | - Deborah A Marshall
- Department of Community Health Sciences, Cumming School of Medicine, University of Calgary, Calgary, Alberta T2N 4Z6, Canada
- Alberta Children's Hospital Research Institute, Department of Medicine, Cumming School of Medicine, University of Calgary, Calgary, Alberta T2N 4Z6, Canada
| | - Loren Adler
- USC-Brookings Schaeffer Initiative for Health Policy, Brookings Institution, Washington, DC 90089, United States
| | - Jose Figueroa
- Department of Health Policy and Management, Harvard T.H. Chan School of Public Health, Boston, MA 02115, United States
- Department of Medicine, Brigham & Women's Hospital and Harvard Medical School, Boston, MA 02115, United States
| | - Simon F Haeder
- Department of Health Policy and Management, School of Public Health, Texas A&M University, College Station, TX 77843, United States
| | - Rita Hamad
- Philip R. Lee Institute for Health Policy Studies, University of California, San Francisco, San Francisco, CA 94158, United States
- Department of Family and Community Medicine, University of California, San Francisco, San Francisco, CA 94110, United States
- Department of Social and Behavioral Sciences, Harvard T.H. Chan School of Public Health, Boston, MA 02115, United States
| | - Inmaculada Hernandez
- Skaggs School of Pharmacy and Pharmaceutical Sciences, University of California, San Diego, San Diego, CA 92093, United States
| | - Corrina Moucheraud
- Department of Health Policy and Management, Fielding School of Public Health, University of California, Los Angeles, Los Angeles, CA 90095, United States
- UCLA Center for Health Policy Research, University of California, Los Angeles, Los Angeles, CA 90024, United States
| | - Sayeh Nikpay
- Division of Health Policy and Management, School of Public Health, University of Minnesota, Minneapolis, MN 55455, United States
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Jiang GY, Urwin JW, Wasfy JH. Medicaid Expansion Under the Affordable Care Act and Association With Cardiac Care: A Systematic Review. Circ Cardiovasc Qual Outcomes 2023; 16:e009753. [PMID: 37339189 DOI: 10.1161/circoutcomes.122.009753] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/02/2022] [Accepted: 04/20/2023] [Indexed: 06/22/2023]
Abstract
BACKGROUND The goal of the Affordable Care Act was to improve health outcomes through expanding insurance, including through Medicaid expansion. We systematically reviewed the available literature on the association of Affordable Care Act Medicaid expansion with cardiac outcomes. METHODS Consistent with Preferred Reporting Items for Systematic Reviews and Meta-Analysis guidelines, we performed systematic searches in PubMed, the Cochrane Library, and Cumulative Index to Nursing and Allied Health Literature using the keywords such as Medicaid expansion and cardiac, cardiovascular, or heart to identify titles published from 1/2014 to 7/2022 that evaluated the association between Medicaid expansion and cardiac outcomes. RESULTS A total of 30 studies met inclusion and exclusion criteria. Of these, 14 studies (47%) used a difference-in-difference study design and 10 (33%) used a multiple time series design. The median number of postexpansion years evaluated was 2 (range, 0.5-6) and the median number of expansion states included was 23 (range, 1-33). Commonly assessed outcomes included insurance coverage of and utilization of cardiac treatments (25.0%), morbidity/mortality (19.6%), disparities in care (14.3%), and preventive care (41.1%). Medicaid expansion was generally associated with increased insurance coverage, reduction in overall cardiac morbidity/mortality outside of acute care settings, and some increase in screening for and treatment of cardiac comorbidities. CONCLUSIONS Current literature demonstrates that Medicaid expansion was generally associated with increased insurance coverage of cardiac treatments, improvement in cardiac outcomes outside of acute care settings, and some improvements in cardiac-focused prevention and screening. Conclusions are limited because quasi-experimental comparisons of expansion and nonexpansion states cannot account for unmeasured state-level confounders.
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Affiliation(s)
- Ginger Y Jiang
- Division of Cardiovascular Medicine (GYJ) and Department of Medicine (JWU), Beth Israel Deaconess Medical Center, Boston, MA. Cardiology Division, Massachusetts General Hospital, Boston, MA (JHW). Harvard Medical School, Boston, MA (GYJ, JWU, JHW)
| | - John W Urwin
- Division of Cardiovascular Medicine (GYJ) and Department of Medicine (JWU), Beth Israel Deaconess Medical Center, Boston, MA. Cardiology Division, Massachusetts General Hospital, Boston, MA (JHW). Harvard Medical School, Boston, MA (GYJ, JWU, JHW)
| | - Jason H Wasfy
- Division of Cardiovascular Medicine (GYJ) and Department of Medicine (JWU), Beth Israel Deaconess Medical Center, Boston, MA. Cardiology Division, Massachusetts General Hospital, Boston, MA (JHW). Harvard Medical School, Boston, MA (GYJ, JWU, JHW)
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Chatterjee P, Sinha S, Reszczynski O, Amin A, Schpero WL. Variation And Changes In The Targeting Of Medicaid Disproportionate Share Hospital Payments. Health Aff (Millwood) 2022; 41:1781-1789. [PMID: 36469825 DOI: 10.1377/hlthaff.2022.00153] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Little is known about how Medicaid disproportionate share hospital payments, which are intended to support hospitals that serve low-income patients, are allocated or whether allocation patterns have changed over time. We employed alternative definitions of targeting, or the degree to which allocations were made in a manner consistent with the statutory goals and intent of the program, to examine disproportionate share hospital payment allocations in forty-nine participating states. The most recent data indicate that 57.2 percent of acute care hospitals received disproportionate share hospital payments, totaling more than $14.5 billion, in 2015. The majority of payments went to hospitals with Medicaid shares above the state-specific median (89.1 percent), hospitals with uncompensated care shares above the state-specific median (60.6 percent), or hospitals deemed as disproportionate share per statutory definitions (64.6 percent). However, among all hospitals receiving these payments, up to 31.6 percent of payments were allocated to hospitals that did not meet a given definition, and 3.2 percent went to hospitals that met none of them. These findings suggest that although the majority of the payments were targeted to hospitals serving low-income patients, opportunities exist to better align allocation with statutory goals and intent or to revise applicable statute.
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Affiliation(s)
- Paula Chatterjee
- Paula Chatterjee , University of Pennsylvania, Philadelphia, Pennsylvania
| | - Soham Sinha
- Soham Sinha, University of Chicago, Chicago, Illinois
| | - Olivia Reszczynski
- Olivia Reszczynski, Medical University of South Carolina, Charleston, South Carolina
| | - Anita Amin
- Anita Amin, Cornell University, New York, New York
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Liu B, Ornstein KA, Frydman JL, Kelley AS, Benn EKT, Siu AL. Use of hospitals in the New York City Metropolitan Region, by race: how separate? How equal in resources and quality? BMC Health Serv Res 2022; 22:1021. [PMID: 35948923 PMCID: PMC9365444 DOI: 10.1186/s12913-022-08414-3] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2022] [Accepted: 07/27/2022] [Indexed: 01/27/2023] Open
Abstract
BACKGROUND Although racial and ethnic minorities disproportionately use some hospitals, hospital-based racial and ethnic composition relative to geographic region and its association with quality indicators has not been systematically analyzed. METHODS We used four race and ethnicity categories: non-Hispanic white (NHW), non-Hispanic black (NHB), Hispanic, and Asian/Pacific Islander/Alaskan Native/American Indian (API/AIAN), as well as a combined non-NHW category, from the 2010 (latest year publicly available) Medicare Institutional Provider & Beneficiary Summary public use file for 84 hospitals in the New York City region. We assessed the relative distribution of race and ethnicity across hospitals grouped at different geographic levels (region, county, hospital referral region [HRR], or hospital service areas [HSA]) using the dissimilarity index. Hospital characteristics included quality star ratings, essential professional services and diagnostic/treatment equipment, bed size, total expenses, and patients with dual Medicare and Medicaid enrollment. We assessed Spearman's rank correlation between hospital-based racial and ethnic composition and quality/structural measures. RESULTS Dissimilarity Index decreases from region (range 30.3-40.1%) to county (range 13.7-23.5%), HRR (range 10.5-27.5%), and HSA (range 12.0-16.9%) levels. Hospitals with larger non-NHW patients tended to have lower hospital ratings and higher proportions of dually-enrolled patients. They were also more likely to be safety net hospitals and non-federal governmental hospitals. CONCLUSIONS In the NYC metropolitan region, there is considerable hospital-based racial and ethnic segregation of Medicare patients among non-NHW populations, extending previous research limited to NHB. Availability of data on racial and ethnic composition of hospitals should be made publicly available for researchers and consumers.
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Affiliation(s)
- Bian Liu
- grid.59734.3c0000 0001 0670 2351Department of Population Health Science and Policy, Icahn School of Medicine at Mount Sinai, New York, NY USA
| | - Katherine A. Ornstein
- grid.59734.3c0000 0001 0670 2351Brookdale Department of Geriatrics and Palliative Medicine, Icahn School of Medicine at Mount Sinai, 1 Gustave L. Levy Place, Box 1640, New York, NY 10029 USA
| | - Julia L. Frydman
- grid.59734.3c0000 0001 0670 2351Brookdale Department of Geriatrics and Palliative Medicine, Icahn School of Medicine at Mount Sinai, 1 Gustave L. Levy Place, Box 1640, New York, NY 10029 USA
| | - Amy S. Kelley
- grid.59734.3c0000 0001 0670 2351Brookdale Department of Geriatrics and Palliative Medicine, Icahn School of Medicine at Mount Sinai, 1 Gustave L. Levy Place, Box 1640, New York, NY 10029 USA ,grid.274295.f0000 0004 0420 1184Geriatric Research, Education, and Clinical Center, James J Peters Veterans Affairs Medical Center, Bronx, NY USA
| | - Emma K. T. Benn
- grid.59734.3c0000 0001 0670 2351Department of Population Health Science and Policy, Icahn School of Medicine at Mount Sinai, New York, NY USA
| | - Albert L. Siu
- grid.59734.3c0000 0001 0670 2351Brookdale Department of Geriatrics and Palliative Medicine, Icahn School of Medicine at Mount Sinai, 1 Gustave L. Levy Place, Box 1640, New York, NY 10029 USA ,grid.274295.f0000 0004 0420 1184Geriatric Research, Education, and Clinical Center, James J Peters Veterans Affairs Medical Center, Bronx, NY USA
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Levine DM, Chalasani R, Linder JA, Landon BE. Association of the Patient Protection and Affordable Care Act With Ambulatory Quality, Patient Experience, Utilization, and Cost, 2014-2016. JAMA Netw Open 2022; 5:e2218167. [PMID: 35713900 PMCID: PMC9206183 DOI: 10.1001/jamanetworkopen.2022.18167] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
IMPORTANCE The Patient Protection and Affordable Care Act (ACA) expanded Medicaid eligibility at the discretion of states to US individuals earning up to 138% of the federal poverty level (FPL) and made private insurance subsidies available to most individuals earning up to 400% of the FPL. Its national impact remains debated. OBJECTIVE To determine the association of the ACA with ambulatory quality, patient experience, utilization, and cost. DESIGN, SETTING, AND PARTICIPANTS This cross-sectional study used difference-in-differences (DiD) analyses comparing outcomes before (2011-2013) and after (2014-2016) ACA implementation for US adults aged 18 to 64 years with income below and greater than or equal to 400% of the FPL. Participants were respondents to the Medical Expenditure Panel Survey, a nationally representative annual survey. Data analysis was performed from January 2021 to March 2022. EXPOSURES ACA implementation. MAIN OUTCOMES AND MEASURES For quality and experience, this study examined previously published composites based on individual measures, including high-value care composites (eg, preventive testing) and low-value care composites (eg, inappropriate imaging), an overall patient experience rating, a physician communication composite, and an access-to-care composite. For utilization, outpatient, emergency, and inpatient encounters and prescribed medicines were examined. Overall and out-of-pocket expenditures were analyzed for cost. RESULTS The total sample included 123 171 individuals (mean [SD] age, 39.9 [13.4] years; 65 034 women [52.8%]). After ACA implementation, adults with income less than 400% of the FPL received increased high-value care (diagnostic and preventive testing) compared with adults with income 400% or higher of the FPL (change from 70% to 72% vs change from 84% to 84%; adjusted DiD, 1.20%; 95% CI, 0.18% to 2.21%; P = .02) with no difference in any other quality composites. Individuals with income less than 400% of the FPL had larger improvements in experience, communication, and access composites compared with those with income greater than or equal to 400% of the FPL (global rating of health, change from 69% to 73% vs change from 79% to 81%; adjusted DiD, 2.12%; 95% CI, 0.18% to 4.05%; P = .03). There were no differences in utilization or cost, except that receipt of primary care increased for those with lower income vs those with higher income (change from 65% to 66% vs change from 80% to 77%; adjusted DiD, 2.97%; 95% CI, 1.18% to 4.77%; P = .001) and total out-of-pocket expenditures decreased for those with lower income vs those with higher income (change from $504 to $439 vs from $757 to $769; adjusted DiD, -$105.50; 95% CI, -$167.80 to -$43.20; P = .001). CONCLUSIONS AND RELEVANCE In this cross-sectional national study, the ACA was associated with improved patient experience, communication, and access and decreased out-of-pocket expenditures, but little or no change in quality, utilization, and total cost.
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Affiliation(s)
- David M. Levine
- Division of General Internal Medicine and Primary Care, Brigham and Women’s Hospital, Boston, Massachusetts
- Harvard Medical School, Boston, Massachusetts
| | - Rohan Chalasani
- Division of General Internal Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Jeffrey A. Linder
- Division of General Internal Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Bruce E. Landon
- Harvard Medical School, Boston, Massachusetts
- Department of Health Care Policy, Harvard Medical School, Boston, Massachusetts
- Division of General Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts
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Enumah SJ, Resnick AS, Chang DC. Association of measured quality with financial health among U.S. hospitals. PLoS One 2022; 17:e0266696. [PMID: 35443004 PMCID: PMC9020707 DOI: 10.1371/journal.pone.0266696] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2022] [Accepted: 03/24/2022] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND High-quality care is a clear objective for hospital leaders, but hospitals must balance investing in quality with financial stability. Poor hospital financial health can precipitate closure, limiting patients' access to care. Whether hospital quality is associated with financial health remains poorly understood. The objective of this study was to compare financial performance at high-quality and low-quality hospitals. METHODS We performed a retrospective observational cohort study of U.S. hospitals using the American Hospital Association and Hospital Compare datasets for years 2013 to 2018. We used multilevel mixed-effects linear and logistic regression models with fixed year effects and random intercepts for hospitals to identify associations between hospitals' measured quality outcomes-30-day hospital-wide readmission rate and the patient safety indicator-90 (PSI-90)-and their financial margins and risk of financial distress in the same year and the subsequent year. Our sample included 20,919 observations from 4,331 unique hospitals. RESULTS In 2018, the median 30-day readmission rate was 15.2 (interquartile range [IQR] 14.8-15.6), the median PSI-90 score was 0.96 (IQR 0.89-1.07), the median operating margin was -1.8 (IQR -9.7-5.9), and 750 (22.7%) hospitals experienced financial distress. Hospitals in the best quintile of readmission rates experienced higher operating margins (+0.95%, 95% CI [0.51-1.39], p < .001) and lower odds of distress (odds ratio [OR] 0.56, 95% CI [0.45-0.70], p < .001) in the same year as compared to hospitals in the worst quintile. Hospitals in the best quintile of PSI-90 had higher operating margins (+0.62%, 95% CI [0.17-1.08], p = .007) and lower odds of financial distress (OR 0.70, 95% CI [0.55-0.89], p = .003) as compared to hospitals in the worst quintile. The results were qualitatively similar for the same-year and lag-year analyses. CONCLUSION Hospitals that deliver high-quality outcomes may experience superior financial performance compared to hospitals with poor-quality outcomes.
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Affiliation(s)
- Samuel J. Enumah
- Department of Surgery, Brigham and Women’s Hospital, Boston, Massachusetts, United States of America
| | - Andrew S. Resnick
- Department of Surgery, Brigham and Women’s Hospital, Boston, Massachusetts, United States of America
- Department of Quality and Safety, Brigham and Women’s Hospital, Boston, Massachusetts, United States of America
| | - David C. Chang
- Department of Surgery, Massachusetts General Hospital, Boston, Massachusetts, United States of America
- Codman Center for Clinical Effectiveness in Surgery, Boston, Massachusetts, United States of America
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