Referral Networks, Racial Inequity, and Hospital Quality for Open Heart Surgery.

Background: Differences in the quality of hospitals where Black and White patients receive coronary artery bypass grafting (CABG) surgery have been documented. We examined the contributions of physician networks to the gap.

Methods: This was a cross-sectional study of all Medicare fee-for-service Black and White patients undergoing elective CABG during 2017 to 2019; the primary care physicians and cardiologists treating them for 12 months before surgery (the patients' physician network); and CABG-performing hospitals within 100 miles of each patient.

Health System Expansion and Changes in Medicare Beneficiary Utilization of Safety Net Providers.

Background: Evidence is limited on insured patients' use of safety net providers as vertically integrated health systems spread throughout the United States.

Objectives: To examine whether market-level health system penetration is associated with: (1) switches in Medicare beneficiaries' usual source of primary care from federally qualified health centers (FQHCs) to health systems; and (2) FQHCs' overall Medicare patient and visit volume.

Research Design: Beneficiary-level discrete-time survival analysis and market-level linear regression analysis using Medicare fee-for-service claims data from 2013 to 2018.

Protocol: A mixed-methods study to evaluate implementation and outcomes of U.S. state telemental health policy expansion during the COVID-19 pandemic.

Background: Until the COVID-19 pandemic, it had not been possible to examine the effect of rapid policy changes surrounding telemental health on patient-reported mental health care access, costs, symptoms, and functioning. Sizable variation in telemental health use by patient race-ethnicity, age, and rurality, and in its adoption across healthcare settings, underscores the need to study equitable dissemination and implementation of high-quality telemental health services in the real world. This protocol describes an explanatory sequential mixed-methods study that aims to examine the effects of state telemental health policy expansion on patient-reported mental health outcomes, as well as the policy-to-practice pathway from the perspectives of state leaders, clinicians, and staff who care for underserved patients.

Implications of Rebalancing Home-Based Care for Family Caregivers to Older Adults.

Over the last several decades, Medicaid has been "rebalancing" services from institutions to the community, increasing support of home- and community-based services (HCBS). These services could potentially substitute for care typically provided by family members, replacing or reducing care from kin. Leveraging one of the most recent Medicaid rebalancing programs, the Balancing Incentive Program (BIP), and using data from the 2008-2016 Health and Retirement Study on 953 Medicaid beneficiaries ages 65 and over with at least one functional limitation, we examined the relationship between exposure to BIP and family and professional caregiving.

Postacute Care for Medicare Advantage Enrollees Who Switched to Traditional Medicare Compared With Those Who Remained in Medicare Advantage.

Importance: Medicare Advantage (MA) plans receive capitated per enrollee payments that create financial incentives to provide care more efficiently than traditional Medicare (TM); however, incentives could be associated with MA plans reducing use of beneficial services. Postacute care can improve functional status, but it is costly, and thus may be provided differently to Medicare beneficiaries by MA plans compared with TM.

Objective: To estimate the association of MA compared with TM enrollment with postacute care use and postdischarge outcomes.

The segregation of physician networks providing care to black and white patients with heart disease: Concepts, measures, and empirical evaluation.

Black-White disparities in cardiac care may be related to physician referral network segregation. We developed and tested new geographic physician network segregation measures. We used Medicare claims to identify Black and White Medicare heart disease patients and map physician networks for 169 hospital referral regions (HRRs) with over 1000 Black patients.

Within-Physician Differences in Patient Sharing Between Primary Care Physicians and Cardiologists Who Treat White and Black Patients With Heart Disease.

Background: Black-White disparities in heart disease treatment may be attributable to differences in physician referral networks. We mapped physician networks for Medicare patients and examined within-physician Black-White differences in patient sharing between primary care physicians and cardiologists.

Methods And Results: Using Medicare fee-for-service files for 2016 to 2017, we identified a cohort of Black and White patients with heart disease and the primary care physicians and cardiologists treating them.

Relationship of POLST to Hospitalization and ICU Care Among Nursing Home Residents in California.

Background: Physician Orders for Life Sustaining Treatment (POLST) document instructions for intensity of care based upon patient care preferences. POLST forms generally reflect patients' wishes and dictate subsequent medical care, but it is not known how POLST use and content among nursing home residents is associated with inpatient utilization across a large population.

Objective: Evaluate the relationship between POLST use and content with hospital utilization among nursing home residents in California.

Changes over time in POLST use and content by race and ethnicity among California nursing home residents.

Background: Physician Orders for Life-Sustaining Treatment (POLST) are commonly used for nursing home (NH) residents. Treatment orders differ across race and ethnicity, presumably related to cultural and socioeconomic variation and levels of access to care and trust. Because national efforts focus on addressing the underpinnings of racial and ethnic differences in treatment (i.

Young Children's Mental Health Improves Following Medicaid Expansion to Low-Income Adults.

Objective: We investigate whether the Affordable Care Act's Medicaid expansion, implemented in 2014, improved the mental health of young children whose parents are in the policy's target population. We study children ages 2 to 3 in families with incomes less than 138% of the federal poverty level.

Methods: We use restricted National Health Interview Survey data covering the United States from 2010 to 2018 to conduct an event study-a flexible version of difference-in-differences-of the Medicaid expansion's effects on Mental Health Indicator values for young children.

Geographic Variation in Medicare Fee-for-Service Health Care Expenditures Before and After the Passage of the Affordable Care Act.

Importance: Geographic variation in Medicare spending is often used as a measure of wasteful spending. A 2013 Institute of Medicine report found that postacute care was a key contributor of geographic variation from 2007 to 2009. However, payment reforms and antifraud efforts implemented after the passage of the Affordable Care Act (ACA) may have reduced geographic variation in spending, especially postacute care spending.

Is Bigger Better?: A Closer Look at Small Health Systems in the United States.

Background: Research on US health systems has focused on large systems with at least 50 physicians. Little is known about small systems.

Objectives: Compare the characteristics, quality, and costs of care between small and large health systems.

The Affordable Care Act Medicaid expansion: A difference-in-differences study of spillover participation in SNAP.

The Affordable Care Act's Medicaid expansion to individuals with adults under 138 percent of the federal poverty level led to insurance coverage for millions of Americans in participating states. This study investigates Medicaid expansion's potential spillover participation in the Supplemental Nutrition Assistance Program (SNAP; formerly the Food Stamp Program). In addition to providing public insurance, the policy connects individuals to SNAP, affecting social determinants of health such as hunger.

Did the Hospital Readmissions Reduction Program Reduce Readmissions without Hurting Patient Outcomes at High Dual-Proportion Hospitals Prior to Stratification?

Since the implementation of Medicare's Hospital Readmissions Reduction Program (HRRP), safety-net hospitals have received a disproportionate share of financial penalties for excess readmissions, raising concerns about the fairness of the policy. In response, the HRRP now stratifies hospitals into five quintiles by low-income Medicare (dual Medicare-Medicaid eligible) stay proportion and compares readmission rates within quintiles. To better understand the potential effects of the revised policy, we used difference-in-differences models to compare changes in 30-day readmission, 30-day mortality, and 90th-day community-dwelling rates after discharge of fee-for-service Medicare beneficiaries hospitalized for acute myocardial infarction, heart failure and pneumonia during 2007-2014, for hospitals in the highest ( = 677) and lowest ( = 678) dual-proportion quintiles before and after the original HRRP implementation in fiscal year 2013.

Care preferences in physician orders for life sustaining treatment in California nursing homes.

Background: Physician Orders for Life-Sustaining Treatment (POLST) facilitates documentation and transition of patients' life-sustaining treatment orders across care settings. Little is known about patient and facility factors related to care preferences within POLST across a large, diverse nursing home population. We describe the orders within POLST among all nursing home (NH) residents in California from 2011 to 2016.

The Affordable Care Act Medicaid Expansion, Social Disadvantage, and the Practice Location Choices of New General Internists.

Background: A recent study found that states that expanded Medicaid under the Affordable Care Act (ACA) gained new general internists who were establishing their first practices, whereas nonexpansion states lost them.

Objective: The objective of this study was to examine the level of social disadvantage of the areas of expansion states that gained new physicians and the areas of nonexpansion states that lost them.

Research Design: We used American Community Survey data to classify commuting zones as high, medium, or low social disadvantage.

Luck of the draw: Role of chance in the assignment of medicare readmissions penalties.

Pay-for-performance programs are one strategy used by health plans to improve the efficiency and quality of care delivered to beneficiaries. Under such programs, providers are often compared against their peers in order to win bonuses or face penalties in payment. Yet luck has the potential to affect performance assessment through randomness in the sorting of patients among providers or through random events during the evaluation period.

Intergenerational Associations between Parents' and Children's Adverse Childhood Experience Scores.

Background: Adverse childhood experiences (ACEs) are stressful childhood events associated with behavioral, mental, and physical illness. Parent experiences of adversity may indicate a child's adversity risk, but little evidence exists on intergenerational links between parents' and children's ACEs. This study examines these intergenerational ACE associations, as well as parent factors that mediate them.

The effects of vertically integrated care on health care use and outcomes in inpatient rehabilitation facilities.

Objective: To understand the effects of receiving vertically integrated care in inpatient rehabilitation facilities (IRFs) on health care use and outcomes.

Data Sources: Medicare enrollment, claims, and IRF patient assessment data from 2012 to 2014.

Study Design: We estimated within-IRF differences in health care use and outcomes between IRF patients admitted from hospitals vertically integrated with the IRF (parent hospital) vs patients admitted from other hospitals.

Effects of the Affordable Care Act Medicaid Expansion on the Distribution of New General Internists Across States.

Background: Some states expanded Medicaid under the Affordable Care Act, boosting their low-income residents' demand for health care, while other states opted not to expand.

Objective: The objective of this study was to determine whether the Medicaid expansion influenced the states selected by physicians just completing graduate medical education for establishing their first practices.

Research Design: Using 2009-2019 data from the American Medical Association Physician Masterfile and information on states' Medicaid expansion status, we estimated conditional logit models to compare where new physicians located during the 6 years following implementation of the expansion to where they located during the 5 years preceding implementation.

The association of vertically integrated care with health care use and outcomes.

Objective: To determine whether vertically integrated hospital and skilled nursing facility (SNF) care is associated with more efficient use of postdischarge care and better outcomes.

Data Sources: Medicare provider, beneficiary, and claims data from 2012 to 2014.

Study Design: We compared facility characteristics, quality of care, and health care use for hospital-based SNFs and "virtually integrated" SNFs (defined as freestanding SNFs with close referral relationships with a single hospital) relative to nonintegrated freestanding SNFs.

Racial and ethnic disparities in care for health system-affiliated physician organizations and non-affiliated physician organizations.

Objective: To assess racial and ethnic disparities in care for Medicare fee-for-service (FFS) beneficiaries and whether disparities differ between health system-affiliated physician organizations (POs) and nonaffiliated POs.

Data Sources: We used Medicare Data on Provider Practice and Specialty (MD-PPAS), Medicare Provider Enrollment, Chain, and Ownership System (PECOS), IRS Form 990, 100% Medicare FFS claims, and race/ethnicity estimated using the Medicare Bayesian Improved Surname Geocoding 2.0 algorithm.

Health system affiliation of physician organizations and quality of care for Medicare beneficiaries who have high needs.

Objective: To test the hypothesis that health systems provide better care to patients with high needs by comparing differences in quality between system-affiliated and nonaffiliated physician organizations (POs) and to examine variability in quality across health systems.

Data Sources: 2015 Medicare Data on Provider Practice and Specialty linked physicians to POs. Medicare Provider Enrollment, Chain, and Ownership System (PECOS) and IRS Form 990 data identified health system affiliations.