US Hospital Service Availability and New 340B Program Participation.

Importance: The US 340B Drug Pricing Program enables eligible hospitals to receive substantial discounts on outpatient drugs to improve hospitals' financial sustainability and maintain access to care for patients who have low income and/or are uninsured. However, it is unclear whether hospitals use program savings to subsidize access as intended. Objective: To evaluate whether the 340B program is associated with improvements in access to hospital-based services and to test whether the association varies by hospital ownership. Design, Setting, and Participants: Difference-in-differences and cohort analysis from 2010 to 2019. Never and newly participating 340B general, acute, nonfederal hospitals in the US using data from the American Hospital Association's Annual Survey of Hospitals merged with hospital and market characteristics. Data were analyzed from January 1, 2023, to January 31, 2024. Exposures: New enrollment in 340B between 2012 and 2018. Main Outcomes and Measures: Total number of unprofitable service lines, ie, substance use, psychiatric (inpatient and outpatient), burn clinic, and obstetrics services; and profitable services, ie, cardiac surgery and orthopedic, oncologic, neurologic, and neonatal intensive services. Results: The study sample comprised a total of 2152 hospitals, 1074 newly participating and 1078 not participating in the 340B program. Participating hospitals were more likely than nonparticipating hospitals to be critical access and teaching hospitals, have higher Medicaid shares, and be located in rural areas and in Medicaid expansion states. At public hospitals, participation in the 340B program was associated with a significant increase in total unprofitable services (0.21; 95% CI, 0.04 to 0.38; P = .02) and marginal increases in substance use (5.4 percentage points [pp]; 95% CI, -0.8 pp to 11.6 pp; P = .09) and inpatient psychiatric (6.5 pp; 95% CI, -0.7 pp to 13.7 pp; P = .09) services. Among nonprofit hospitals, there was no significant association between 340B and service offerings (profitable and unprofitable) except for an increase in oncologic services (2.5 pp; 95% CI, 0.0 pp to 5.0 pp; P = .05). Conclusions and Relevance: The finding of the cohort study indicate that participation in the 340B program was associated with an increase in unprofitable services among newly participating public hospitals. Nonprofit hospitals were largely unaffected. These findings suggest that public hospitals responded to 340B savings by improving patient access, whereas nonprofits did not. This heterogeneous response should be considered when evaluating the eligibility criteria for the 340B program and how it affects social welfare.

Building Data Infrastructure for Disease-Focused Health Economics Research.

BACKGROUND: Data infrastructure for cancer research is centered on registries that are often augmented with payer or hospital discharge databases, but these linkages are limited. A recent alternative in some states is to augment registry data with All-Payer Claims Databases (APCDs). These linkages capture patient-centered economic outcomes, including those driven by insurance and influence health equity, and can serve as a prototype for health economics research. OBJECTIVES: To describe and assess the utility of a linkage between the Colorado APCD and Colorado Central Cancer Registry (CCCR) data for 2012-2017. RESEARCH DESIGN, PARTICIPANTS, AND MEASURES: This cohort study of 91,883 insured patients evaluated the Colorado APCD-CCCR linkage on its suitability to assess demographics, area-level data, insurance, and out-of-pocket expenses 3 and 6 months after cancer diagnosis. RESULTS: The linkage had high validity, with over 90% of patients in the CCCR linked to the APCD, but gaps in APCD health plans limited available claims at diagnosis. We highlight the advantages of the CCCR-APCD, such as granular race and ethnicity classification, area-level data, the ability to capture supplemental plans, medical and pharmacy out-of-pocket expenses, and transitions in insurance plans. CONCLUSIONS: Linked data between registries and APCDs can be a cornerstone of a robust data infrastructure and spur innovations in health economics research on cost, quality, and outcomes. A larger infrastructure could comprise a network of state APCDs that maintain linkages for research and surveillance.

Treatment Disparities in Radiation and Hormone Therapy Among Women Covered by Medicaid vs Private Insurance in Cancer Registry and Claims Data.

Importance: Prior research has reported undertreatment among patients with cancer who are insured by Medicaid, but this finding may be due, in part, to incomplete data in cancer registries. Objective: To compare disparities in radiation and hormone therapy between women with breast cancer covered by Medicaid and those with private insurance using the Colorado Central Cancer Registry (CCCR) and CCCR data supplemented with All Payer Claims Data (APCD). Design, Setting, and Participants: This observational cohort study included women aged 21 to 63 years who received breast cancer surgery. We linked the CCCR and Colorado APCD to identify Medicaid and privately insured women who were newly diagnosed with invasive, nonmetastatic breast cancer between January 1, 2012, and December 31, 2017. In the radiation treatment analysis, we narrowed the sample to women who received breast-conserving surgery (Medicaid, n = 1408; private, n = 1984) and in the hormone therapy analysis, we selected women who were hormone-receptor positive (Medicaid, n = 1156; private, n = 1667). Main Outcomes and Measures: We used logistic regression to estimate the likelihood of treatment within 12 months to assess whether the results varied between data sources. Results: There were 3392 and 2823 participants in the radiation and hormone therapy cohorts, respectively. The mean (SD) age was 51.71 (8.30) years in the radiation therapy cohort, and 52.00 (8.16) years in the hormone therapy cohort. Among the participants, there were 140 (4%) and 105 (4%) who were Black non-Hispanic, 499 (15%) and 406 (14%) who were Hispanic, 2602 (77%) and 2190 (78%) were White, and 151 (4%) and 122 (4%) were other/unknown in the radiation and hormone therapy cohorts, respectively. A higher percentage of women were aged 50 years or younger in the Medicaid samples (40% vs 34% in the privately insured sample) and identified as non-Hispanic Black (about 7%) or Hispanic (approximately 24%). Treatment was underreported in both sources, but to a lesser extent in the APCD (2.5% and 2.0% for Medicaid and private insurance, respectively) compared with CCCR (19.5% and 13.3% for Medicaid and private insurance, respectively). Using CCCR data, Women with Medicaid insurance were 4 (95% CI, -8 to -1; P = .02) and 10 (95% CI, -14 to -6; P < .001) percentage points less likely to have a record of radiation and hormone therapy compared with privately insured women, respectively. Using combined CCCR and APCD, no statistically significant disparity was observed in radiation or hormone therapy between Medicaid-insured and privately insured women. Conclusions and Relevance: Among women with breast cancer covered by Medicaid vs private insurance, cancer treatment disparities may be overestimated if based solely on cancer registry data.

Medicaid Payment For Postpartum Long-Acting Reversible Contraception Prompts More Equitable Use.

To increase access to highly effective contraception and improve reproductive autonomy, a growing number of state Medicaid programs pay for the provision of immediate postpartum long-acting reversible contraception (LARC) in addition to providing a global payment for maternity care. Using Pregnancy Risk Assessment Monitoring System data, we examined postpartum LARC use both overall and by race and ethnicity among respondents with Medicaid-paid births during the period 2012-18 in eight states that implemented immediate postpartum LARC payment and eight states without it. Using a quasi-experimental difference-in-differences design, we found that the policy resulted in an overall 2.1-percentage-point increase in postpartum LARC use. Our triple-differences analysis found no significant change among White mothers and a 3.7-percentage-point increase in use among Black mothers compared with White mothers. Additional research is needed to determine whether this increase was aligned with patients' preferences and whether hospitals' immediate postpartum LARC policies and practices take a patient-centered approach that supports reproductive autonomy and equity.

Understanding the relationship between nonprofit hospital community benefit spending and system membership: An analysis of independent hospital acquisitions.

The Internal Revenue Service (IRS) requires nonprofit hospitals to report community benefit spending to justify their nonprofit tax exemption. We examined whether nonprofit hospital acquisitions influence the amount and type community benefit spending. We analyzed 2011-2018 data on urban, nonprofit hospitals. The analysis dataset included 57 hospitals that were acquired and a matched control group. We estimated difference-in-differences specifications to measure the effect of acquisitions on total community benefit spending, and three subcategories - clinical, population health, and other spending types. We found that acquisitions led to decreased population health spending (-$0.32 million, p < 0.01) and other spending categories (-$1.5 million, p < 0.05), but no significant change in total or clinical spending. If the acquirer was located out-of-state, total community benefit spending declined by $2.4 million (p < 0.10). Our findings support the need for community benefit spending to be considered, along with quality, efficiency, and prices, when evaluating the welfare impact of acquisitions.

The role of all-payer claims databases to expand central cancer registries: Experience from Colorado.

OBJECTIVE: To evaluate the quality of a multiyear linkage between the Colorado all-payer claims database (APCD) and the Colorado Central Cancer Registry. DATA SOURCES: Secondary 2012-2017 data from the APCD and the Colorado Cancer Registry. STUDY DESIGN: Descriptive analysis of the proportion of cases captured by the linkage in relation to the cases reported by the registry. DATA COLLECTION/EXTRACTION METHODS: We used probabilistic linkage to combine records from both data sources for all patients diagnosed with cancer. RESULTS: We successfully linked 93% of the 146,884 patients in the registry. Approximately 63% of linked patients were perfect matches on five identifiers. Of partial matches, 81.6% were matched on four identifiers with missing or partial Social Security Numbers. The linkage rate was lower for uninsured patients at diagnosis (74.7%) or patients with private plans (89.4%) but close to 100% for Medicare and Medicaid enrollees. Most of the 29% of patients who did not have claims at the time of diagnosis were covered by private plans that may not submit claims. CONCLUSIONS: APCD-registry linkages are a promising source of data to conduct population-based research from multiple payers. However, not all payers submit claims, and the quality of the data may vary by state.

Nonprofit Hospital Community Benefits: Collaboration With Local Health Departments to Address the Drug Epidemic.

BACKGROUND: Nonprofit hospitals (NFPs) are required to provide community benefits, which have been historically focused on provision of medical care, to keep their tax exemption status. To increase hospital investment in community health, the Patient Protection and Affordable Care Act required NFPs to conduct community health needs assessments and address identified needs. Some states have leveraged this provision to encourage collaboration between NFPs and local health departments (LHDs) in local health planning. OBJECTIVE: The objective of this study was to examine the association of NFP-LHD collaboration in local health planning targeting drug use, with drug-induced mortality. RESEARCH DESIGN: We conducted difference-in-differences analyses using drug-induced mortality data from 2009 to 2016, encompassing the first 3 years after NFP-LHD collaboration in local health planning specific to drug use. We evaluated drug-induced mortality in 22 counties in which collaboration was required in comparison with that in 198 control counties. We used data collected from implementation strategy reports by NFPs and combined it with data on hospital characteristics, as well as state-level and county-level factors associated with drug-induced mortality. MEASURES: The primary outcome was county-level drug-induced mortality per 100,000 population. RESULTS: Counties, in which NFP-LHD collaboration in local health planning was required and in which NFPs and LHDs jointly prioritized drug use, experienced a deceleration in drug-induced mortality of ~8 deaths per 100,000 population compared with the mortality rate they would have experienced without collaboration. CONCLUSIONS: Collaboration between NFPs and LHDs to address drug use was associated with a deceleration in drug-induced mortality. Policymakers can leverage community benefit regulation to encourage NFP-LHD collaboration in local health planning.

Can Collaboration Between Nonprofit Hospitals and Local Health Departments Influence Population Health Investments by Nonprofit Hospitals?

BACKGROUND: The patient protection and Affordable Care Act (ACA) sought to improve population health by requiring nonprofit hospitals (NFPs) to conduct triennial community health needs assessments and address the identified needs. In this context, some states have encouraged collaboration between hospitals and local health department (LHD) to increase the focus of community benefit spending onto population health. OBJECTIVES: The aim was to examine whether a 2012 state law that required NFPs to collaborate with LHDs in local health planning influenced hospital population health improvement spending. RESEARCH DESIGN: We merged Internal Revenue Service data on NFP community benefit spending with data on hospital, county and state-level characteristics and estimated a difference-in-differences specification of hospital population health spending in 2009-2016 that compared the difference between hospitals that were required to collaborate with LHDs to those that were not, before and after the requirement. MEASURES: The primary outcome was population health spending divided by operating expenses. RESULTS: We found that the requirement for hospital-LHD collaboration was associated with increased mean population health spending of ∼$393,000-$786,000 (P=0.03). This association was significant in 2015-2016, perhaps reflecting the lag between assessments and implementation. Urban hospitals were responsible for most of the increased spending. CONCLUSIONS: Policymakers have sought to encourage hospitals to increase their investment in population health; however, overall community benefit spending on population health has remained flat. We found that requiring hospital-LHD collaboration was associated with increased hospital investment in population health. It may be that hospitals increase population health spending because collaboration improves expected effectiveness or increases hospital accountability.

Association Between Increased Hospital Reimbursement for Cardiac Rehabilitation and Utilization of Cardiac Rehabilitation by Medicare Beneficiaries: An Interrupted Time Series.

BACKGROUND: Although cardiac rehabilitation (CR) is a Class I Guideline recommendation, and has been shown to be a cost-effective intervention after a cardiac event, it has been reimbursed at levels insufficient to cover hospital operating costs. In January 2011, Medicare increased payment for CR in hospital outpatient settings by ≈180%. We evaluated the association between this payment increase and participation in CR of eligible Medicare beneficiaries to better understand the relationship between reimbursement policy and CR utilization. METHODS: From a 5% Medicare claims sample, we identified patients with acute myocardial infarction, coronary artery bypass surgery, percutaneous coronary intervention, or cardiac valve surgery between January 1, 2009 and September 30, 2012, alive 30 days after their event, with continuous enrollment in Medicare fee-for-service, Part A/B for 4 months. Trends and changes in CR participation were estimated using an interrupted time series approach with a hierarchical logistic model, hospital random intercepts, adjusted for patient, hospital, market, and seasonality factors. Estimates were expressed using average marginal effects on a percent scale. RESULTS: Among 76 695 eligible patients, average annual CR participation was 19.5% overall. In the period before payment increase, adjusted annual participation grew by 1.1 percentage points (95% CI, 0.48-2.4). No immediate change occurred in CR participation when the new payment was implemented. In the period after payment increase, on average, 20% of patients participated in CR annually. The annual growth rate in CR participation slowed in the post-period by 1.3 percentage points (95% CI, -2.4 to -0.12) compared with the prior period. Results were somewhat sensitive to time window variations. CONCLUSIONS: The 2011 increase in Medicare reimbursement for CR was not associated with an increase in participation. Future studies should evaluate whether payment did not reach a threshold to incentivize hospitals or if hospitals were not sensitive to reimbursement changes.

Cost Analysis of Dialysis Access Maintenance Interventions across Physician Specialties in U.S. Medicare Beneficiaries.

Background Dialysis maintenance interventions account for billions of dollars in U.S. Medicare spending and are performed by multiple medical specialties. Whether Medicare costs differ by physician specialty is, to the knowledge of the authors, not known. Purpose To assess patency-adjusted costs of endovascular dialysis access maintenance by physician specialty. Materials and Methods In this retrospective longitudinal cohort study, patients who were beneficiaries of Medicare undergoing their first arteriovenous access placement in 2009 were identified by using billing codes in the 5% Limited Data Set. By tracking their utilization data through 2014, postintervention primary patency and aggregate payments associated with maintenance interventions were calculated. Unadjusted payments per year of access patency gain were compared across physician specialty. A general linear mixed-effects model adjusted for covariates was used, as follows: patient characteristics, access type (fistula vs graft), clinical severity, type of intervention (angioplasty, stent, thrombolysis), clinical location (hospital outpatient vs office-based laboratory), and resource utilization (operating room use, anesthesia use). Results First arteriovenous access was performed in 1479 beneficiaries (mean age, 63 years ± 15 [standard deviation]; 820 men) in 2009. Through 2014, 8166 maintenance interventions were performed in this cohort. Unadjusted mean Medicare payments for each incremental year of patency were as follows: $71 000 for radiologists, $89 000 for nephrologists, and $174 000 for surgeons. Billing for operating room (41.8% [792 of 1895], surgery; 10.2% [277 of 2709], nephrology; and 31.1% [1108 of 3562], radiology) and anesthesia (19.9% [377 of 1895], surgery; 2.6% [70 of 2709], nephrology; 4.7% [170 of 3562], radiology) varied by specialty and accounted for 407% and 132% higher payments, respectively. After adjusting for clinical severity and location, type of intervention, and resource utilization, nephrologists and surgeons had 59% (95% confidence interval: 44%, 73%; P < .001) and 57% (95% confidence interval: 43%, 72%; P < .001) higher payments, respectively, for the same patency gain compared with radiologists. Operating room use and anesthesia services were major drivers of higher cost, with 407% (95% confidence interval: 374%, 443%; P < .001) and 132% (95% confidence interval: 116%, 150%; P < .001) higher costs, respectively. Conclusion Patency-adjusted payments for hemodialysis access maintenance differed by physician specialty, driven partly by discrepant rates of billing for operating room and anesthesia use. © RSNA, 2020 Online supplemental material is available for this article. See also the editorial by White in this issue.

A Quasi-Experimental Analysis of Lethal Means Assessment and Risk for Subsequent Suicide Attempts and Deaths.

BACKGROUND: Counseling on access to lethal means is highly recommended for patients with suicide risk, but there are no formal evaluations of its impact in real-world settings. OBJECTIVE: Evaluate whether lethal means assessment reduces the likelihood of suicide attempt and death outcomes. DESIGN: Quasi-experimental design using an instrumental variable to overcome confounding due to unmeasured patient characteristics that could influence provider decisions to deliver lethal means assessment. SETTING: Kaiser Permanente Colorado, an integrated health system serving over 600,000 members, with comprehensive capture of all electronic health records, medical claims, and death information. PARTICIPANTS: Adult patients who endorsed suicide ideation on the Patient Health Questionnaire-9 (PHQ-9) depression screener administered in behavioral health and primary care settings from 2010 to 2016. INTERVENTIONS: Provider documentation of lethal means assessment in the text of clinical notes, collected using a validated Natural Language Processing program. MEASUREMENTS: Main outcome was ICD-9 or ICD-10 codes for self-inflicted injury or suicide death within 180 days of index PHQ-9 event. RESULTS: We found 33% of patients with suicide ideation reported on the PHQ-9 received lethal means assessment in the 30 days following identification. Lethal means assessment reduced the risk of a suicide attempt or death within 180 days from 3.3 to 0.83% (p = .034, 95% CI = .069-.9). LIMITATIONS: Unmeasured suicide prevention practices that co-occur with lethal means assessment may contribute to the effects observed. CONCLUSIONS: Clinicians should expand the use of counseling on access to lethal means, along with co-occurring suicide prevention practices, to all patients who report suicide ideation.

The Impact of Home Health Physical Therapy on Medicare Beneficiaries With a Primary Diagnosis of Dementia.

BACKGROUND: Dementia is a leading cause of disability for adults older than 65 years. Exercise intervention slows functional decline and improves balance; however, the efficacy of physical therapy (PT) services for persons with dementia is unknown. The purpose of this study is to assess the effect of home health PT services on physical function for Medicare beneficiaries with a primary diagnosis of dementia. DESIGN: Observational cohort study using a combined Medicare data set of home health beneficiaries; we performed augmented inverse probability weighted regression with demographic, comorbidity, and symptom-level characteristics analyzed as covariates. SETTING: Home healthcare, United States, 2012. PARTICIPANTS: Medicare beneficiaries who had a primary diagnosis of dementia and home health function evaluations at discharge (n = 1477). INTERVENTION: PT treatment, examined by (1) any PT and (2) PT visit number. MEASUREMENT: Improvement in composite activity of daily living (ADL) scores from home health admit to discharge. RESULTS: Any PT increased the probability of improvement in ADLs by 15.2% (P < .001). Compared to 1 to 5 PT visits, 6 to 13 visits increased the probability of ADL improvement by 11.6% (P < .001). CONCLUSION: PT intervention is beneficial for ADL function improvement in Medicare home health beneficiaries with a primary diagnosis of dementia. J Am Geriatr Soc 68:867-871, 2020.

Risk of ESKD in Older Live Kidney Donors with Hypertension.

BACKGROUND AND OBJECTIVES: Hypertension in older kidney donor candidates is viewed as safe. However, hypertension guidelines have evolved and long-term outcomes have not been explored. We sought to quantify the 15-year risk of ESKD and mortality in older donors (≥50 years old) with versus those without hypertension. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS: A United States cohort of 24,533 older donors from 1999 to 2016, including 2265 with predonation hypertension, were linked to Centers for Medicare and Medicaid Services data and the Social Security Death Master File to ascertain ESKD development and mortality. The exposure of interest was predonation hypertension. From 2004 to 2016, hypertension was defined as documented predonation use of antihypertensive therapy, regardless of systolic BP or diastolic BP; from 1999 to 2003, when there was no documentation of antihypertensive therapy, hypertension was defined as predonation systolic BP ≥140 or diastolic BP ≥90 mm Hg. RESULTS: Older donors were 82% white, 6% black, 7% Hispanic, and 3% Asian. The median follow-up was 7.1 years (interquartile range, 3.4-11.1; maximum, 18). There were 24 ESKD and 252 death events during the study period. The 15-year risk of ESKD was 0.8% (95% confidence interval [95% CI], 0.4 to 1.6) for donors with hypertension (mean systolic BP, 138 mm Hg) versus 0.2% (95% CI, 0.1 to 0.4) for donors without hypertension (mean systolic BP, 123 mm Hg; adjusted hazard ratio, 3.04; 95% CI, 1.28 to 7.22; P=0.01). When predonation antihypertensive therapy was available, the risk of ESKD was 6.21-fold higher (95% CI, 1.20 to 32.17; P=0.03) for donors using antihypertensive therapy (mean systolic BP, 132 mm Hg) versus those not using antihypertensive therapy (mean systolic BP, 124 mm Hg). There was no significant association between donor hypertension and 15-year mortality (hazard ratio, 1.18; 95% CI, 0.84 to 1.66; P=0.34). CONCLUSIONS: Compared with older donors without hypertension, older donors with hypertension had higher risk of ESKD, but not mortality, for 15 years postdonation. However, the absolute risk of ESKD was small.

State Laws and Nonprofit Hospital Community Benefit Spending.

OBJECTIVE: To determine the association of state laws on nonprofit hospital community benefit spending. DESIGN: We used multivariate models to estimate the association between different types of state-level community benefit laws and nonprofit hospital community benefit spending from tax filings. SETTING: All 50 US states. PARTICIPANTS: A total of 2421 nonprofit short-term acute care hospital organizations that filled an internal revenue service Form 990 and Schedule H for calendar during years 2009-2015. RESULTS: Between 2009 and 2015, short-term acute care hospitals spent an average of $46 billion per year in total, or $20 million per hospital on community benefit activities. Exposure to a state-level community benefit law of any type was associated with an $8.42 (95% confidence interval: 1.20-15.64) per $1000 of total operating expense greater community benefit spending. Spending amounts and patterns varied on the basis of the type of community benefit law and hospital urbanicity. CONCLUSIONS: State laws are associated with nonprofit hospital community benefit spending. Policy makers can use community benefit laws to increase nonprofit hospital engagement with public health.

Urban-Rural Differences in Service Utilization and Costs of Care for Racial-Ethnic Groups Hospitalized With Poststroke Aphasia.

OBJECTIVE: Although residence is a key contributor to cost and utilization in stroke patient care, its contribution to the care of persons with aphasia (PWA) is unknown. The objective of this study was to use discharge-level hospital inpatient data to examine the influence of patient residence (rural vs urban) and race-ethnicity on service utilization and cost of care among PWA. DESIGN: Cross-sectional. SETTING: Administrative data from acute care hospitals in the state of North Carolina. PARTICIPANTS: Individuals (N=4381) with poststroke aphasia. INTERVENTIONS: N/A. MAIN OUTCOME MEASURES: Length of stay (LOS), speech-language pathology (SLP) service utilization, costs of care. METHODS: The 2011-2012 Healthcare Cost and Utilization Project State Inpatient Database data were analyzed to examine the effect of rural or urban residence on LOS, SLP service utilization, as well as total inpatient and SLP service costs. These outcomes were further analyzed across both residence and racial groups (non-Hispanic white and non-Hispanic black). Outcomes were analyzed using generalized linear model. RESULTS: Both rural and urban black PWA experienced longer average LOS after controlling for demographics, illness severity, and the hospital where they received care. Rural blacks experienced longer LOS, received greater SLP services, and incurred greater average total hospital costs than their rural white counterparts after adjusting for differences in their demographics and stroke or illness severity. The differences were attenuated after controlling for the hospital where they received care. CONCLUSIONS: For PWA, race-ethnicity has a larger effect on average total medical costs, SLP service utilization, and LOS than residence. It is unclear how and why blacks with aphasia have greater service utilization and costs in acute care, yet their aphasia outcomes are worse. Future studies are required to explore potential factors such as quality of care.

Understanding The Relationship Between Medicaid Expansions And Hospital Closures.

Decisions by states about whether to expand Medicaid under the Affordable Care Act (ACA) have implications for hospitals' financial health. We hypothesized that Medicaid expansion of eligibility for childless adults prevents hospital closures because increased Medicaid coverage for previously uninsured people reduces uncompensated care expenditures and strengthens hospitals' financial position. We tested this hypothesis using data for the period 2008-16 on hospital closures and financial performance. We found that the ACA's Medicaid expansion was associated with improved hospital financial performance and substantially lower likelihoods of closure, especially in rural markets and counties with large numbers of uninsured adults before Medicaid expansion. Future congressional efforts to reform Medicaid policy should consider the strong relationship between Medicaid coverage levels and the financial viability of hospitals. Our results imply that reverting to pre-ACA eligibility levels would lead to particularly large increases in rural hospital closures. Such closures could lead to reduced access to care and a loss of highly skilled jobs, which could have detrimental impacts on local economies.

Coordination Program Reduced Acute Care Use And Increased Primary Care Visits Among Frequent Emergency Care Users.

Many high utilizers of the emergency department (ED) have public insurance, especially through Medicaid. We evaluated how participation in Bridges to Care (B2C)-an ED-initiated, multidisciplinary, community-based program-affected subsequent ED use, hospital admissions, and primary care use among publicly insured or Medicaid-eligible high ED utilizers. During the six months after the B2C intervention was completed, participants had significantly fewer ED visits (a reduction of 27.9 percent) and significantly more primary care visits (an increase of 114.0 percent), compared to patients in the control group. In a subanalysis of patients with mental health comorbidities, we found that recipients of B2C services had significantly fewer ED visits (a reduction of 29.7 percent) and hospitalizations (30.0 percent), and significantly more primary care visits (an increase of 123.2 percent), again compared to patients in the control group. The B2C program reduced acute care use and increased the number of primary care visits among high ED utilizers, including those with mental health comorbidities.

Value of Public Health Funding in Preventing Hospital Bloodstream Infections in the United States.

OBJECTIVES: To estimate the association of 1 activity of the Prevention and Public Health Fund with hospital bloodstream infections and calculate the return on investment (ROI). METHODS: The activity was funded for 1 year (2013). A difference-in-differences specification evaluated hospital standardized infection ratios (SIRs) before funding allocation (years 2011 and 2012) and after funding allocation (years 2013 and 2014) in the 15 US states that received the funding compared with hospital SIRs in states that did not receive the funding. We estimated the association of the funded public health activity with SIRs for bloodstream infections. We calculated the ROI by dividing cost offsets from infections averted by the amount invested. RESULTS: The funding was associated with a 33% (P < .05) reduction in SIRs and an ROI of $1.10 to $11.20 per $1 invested in the year of funding allocation (2013). In 2014, after the funding stopped, significant reductions were no longer evident. CONCLUSIONS: This activity was associated with a reduction in bloodstream infections large enough to recoup the investment. Public health funding of carefully targeted areas may improve health and reduce health care costs.

Recommendations for Methicillin-Resistant Staphylococcus aureus Prevention in Adult ICUs: A Cost-Effectiveness Analysis.

OBJECTIVE: Patients in the ICU are at the greatest risk of contracting healthcare-associated infections like methicillin-resistant Staphylococcus aureus. This study calculates the cost-effectiveness of methicillin-resistant S aureus prevention strategies and recommends specific strategies based on screening test implementation. DESIGN: A cost-effectiveness analysis using a Markov model from the hospital perspective was conducted to determine if the implementation costs of methicillin-resistant S aureus prevention strategies are justified by associated reductions in methicillin-resistant S aureus infections and improvements in quality-adjusted life years. Univariate and probabilistic sensitivity analyses determined the influence of input variation on the cost-effectiveness. SETTING: ICU. PATIENTS: Hypothetical cohort of adults admitted to the ICU. INTERVENTIONS: Three prevention strategies were evaluated, including universal decolonization, targeted decolonization, and screening and isolation. Because prevention strategies have a screening component, the screening test in the model was varied to reflect commonly used screening test categories, including conventional culture, chromogenic agar, and polymerase chain reaction. MEASUREMENTS AND MAIN RESULTS: Universal and targeted decolonization are less costly and more effective than screening and isolation. This is consistent for all screening tests. When compared with targeted decolonization, universal decolonization is cost-saving to cost-effective, with maximum cost savings occurring when a hospital uses more expensive screening tests like polymerase chain reaction. Results were robust to sensitivity analyses. CONCLUSIONS: As compared with screening and isolation, the current standard practice in ICUs, targeted decolonization, and universal decolonization are less costly and more effective. This supports updating the standard practice to a decolonization approach.

Greater healthcare utilization and costs among Black persons compared to White persons with aphasia in the North Carolina stroke belt.

PURPOSE: To examine racial differences in healthcare utilization and costs for persons with aphasia (PWA) being treated in acute care hospitals in North Carolina (NC). METHODS: NC Healthcare Cost and Utilization Project State Inpatient Database (HCUP-SID) data from 2011-2012 were analyzed to examine healthcare utilization and costs of care for stroke patients with aphasia. Analyses emphasized length of stay, charges and cost of general hospital services. Generalized linear models (GLM) were constructed to determine the impact of demographic characteristics, stroke/illness severity, and observed hospital characteristics on utilization and costs. Hospital fixed effects were included to yield within-hospital estimates of disparities. RESULTS: GLM models demonstrated that Blacks with aphasia experienced 1.9days longer lengths of stay compared to Whites with aphasia after controlling for demographic characteristics, 1.4days controlling for stroke/illness severity, 1.2days controlling for observed hospital characteristics, and ~1 extra day controlling for unobserved hospital characteristics. Similarly, Blacks accrued ~$2047 greater total costs compared to Whites after controlling for demographic characteristics, $1659 controlling for stroke/illness severity, $1338 controlling for observed hospital characteristics, and ~$1311 greater total costs after controlling for unobserved hospital characteristics. CONCLUSIONS: In the acute hospital setting, Blacks with aphasia utilize greater hospital services during longer hospitalizations and at substantially higher costs in the state of NC. A substantial portion of the adjusted difference was related to the hospital treating the patient. However, even after controlling for the hospital, the differences remained clinically and statistically significant.