Technology, data, people, and partnerships in addressing unmet social needs within Medicaid Managed Care.

BACKGROUND: Individuals with unmet social needs experience adverse health outcomes and are subject to greater inequities in health and social outcomes. Given the high prevalence of unmet needs among Medicaid enrollees, many Medicaid managed care organizations (MCOs) are now screening enrollees for unmet social needs and connecting them to community-based organizations (CBOs) with knowledge and resources to address identified needs. The use of screening and referral technology and data sharing are often considered key components in programs integrating health and social services. Despite this emphasis on technology and data collection, research suggests substantial barriers exist in operationalizing effective systems. METHODS: We used qualitative methods to examine cross-sector perspectives on the use of data and technology to facilitate MCO and CBO partnerships in Kentucky, a state with high Medicaid enrollment, to address enrollee social needs. We recruited participants through targeted sampling, and conducted 46 in-depth interviews with 26 representatives from all six Kentucky MCOs and 20 CBO leaders. Qualitative descriptive analysis, an inductive approach, was used to identify salient themes. RESULTS: We found that MCOs and CBOs have differing levels of need for data, varying incentives for collecting and sharing data, and differing valuations of what data can or should do. Four themes emerged from interviewees' descriptions of how they use data, including 1) to screen for patient needs, 2) to case manage, 3) to evaluate the effectiveness of programs, and 4) to partner with each other. Underlying these data use themes were areas of alignment between MCOs/CBOs, areas of incongruence, and areas of tension (both practical and ideological). The inability to interface with community partners for data privacy and ownership concerns contributes to division. Our findings suggest a disconnect between MCOs and CBOs regarding terms of their technology interfacing despite their shared mission of meeting the unmet social needs of enrollees. CONCLUSIONS: While data and technology can be used to identify enrollee needs and determine the most critical need, it is not sufficient in resolving challenges. People and relationships across sectors are vital in connecting enrollees with the community resources to resolve unmet needs.

A Postpartum Weight Loss-focused Stepped-care Intervention in a Military Population: A Randomized Controlled Trial.

OBJECTIVE: Postpartum weight retention is associated with adverse health among both civilian and military women. PURPOSE: The current study evaluated a stepped-care weight management intervention, Moms Fit 2 Fight, adapted for use in a pregnant and postpartum military population. METHODS: Active duty women and other TRICARE beneficiaries (N = 430) were randomized to one of three conditions: gestational weight gain only (GWG-only) intervention (n =144), postpartum weight loss only (PPWL-only) intervention (n =142), or a combined GWG + PPWL intervention (n = 144). Those participants who received the PPWL intervention (i.e., the PPWL-only and GWG+PPWL conditions) were combined consistently with the pre-registered protocol and compared to those participants who did not receive the PPWL intervention in the primary analyses. Primary outcome data (i.e., postpartum weight retention) were obtained at 6-months postpartum by unblinded data collectors, and intent-to-treat analyses were conducted. RESULTS: Retention at 6-months postpartum was 88.4%. Participants who received the PPWL intervention retained marginally less weight (1.31 kg) compared to participants that received the GWG-only intervention (2.39 kg), with a difference of 1.08 kg (p = .07). None of the measured covariates, including breastfeeding status, were significantly associated with postpartum weight retention. Of the participants who received the PPWL intervention, 48.1% participants returned to their pre-pregnancy weight at 6-months postpartum, with no significant differences compared to those who received the GWG-only intervention. CONCLUSIONS: A behavioral intervention targeting diet and physical activity during the postpartum period had a trend for reduced postpartum weight retention. CLINICAL TRIAL INFORMATION: The trial is registered on clinicaltrials.gov (NCT03057808).

Since postpartum weight retention is associated with negative health outcomes among women in the military and women in the general population, the Moms Fit 2 Fight study evaluated a stepped-care weight management intervention among active duty women and other military health insurance beneficiaries. Participants (N = 430) were recruited in their first trimester of pregnancy and randomized to one of three conditions: pregnancy weight gain-only intervention, postpartum weight loss (PPWL)-only intervention, or a combined pregnancy weight gain and PPWL intervention. Participants who received the PPWL intervention (i.e., the participants who received the PPWL-only intervention or the combined intervention) were compared to the participants who did not receive the PPWL intervention, based on weight retention at 6-months postpartum. Participants who received the PPWL intervention retained marginally less weight compared to participants that did not receive the PPWL intervention. Thus, this behavioral intervention targeting diet and physical activity during the postpartum period had a trend for reducing postpartum weight retention, which may be beneficial for achieving military fitness standards and avoiding escalating obesity over multiple pregnancies.

Combined impact of Medicare's hospital pay for performance programs on quality and safety outcomes is mixed.

BACKGROUND: Three major hospital pay for performance (P4P) programs were introduced by the Affordable Care Act and intended to improve the quality, safety and efficiency of care provided to Medicare beneficiaries. The financial risk to hospitals associated with Medicare's P4P programs is substantial. Evidence on the positive impact of these programs, however, has been mixed, and no study has assessed their combined impact. In this study, we examined the combined impact of Medicare's P4P programs on clinical areas and populations targeted by the programs, as well as those outside their focus. METHODS: We used 2007-2016 Healthcare Cost and Utilization Project State Inpatient Databases for 14 states to identify hospital-level inpatient quality indicators (IQIs) and patient safety indicators (PSIs), by quarter and payer (Medicare vs. non-Medicare). IQIs and PSIs are standardized, evidence-based measures that can be used to track hospital quality of care and patient safety over time using hospital administrative data. The study period of 2007-2016 was selected to capture multiple years before and after introduction of program metrics. Interrupted time series was used to analyze the impact of the P4P programs on study outcomes targeted and not targeted by the programs. In sensitivity analyses, we examined the impact of these programs on care for non-Medicare patients. RESULTS: Medicare P4P programs were not associated with consistent improvements in targeted or non-targeted quality and safety measures. Moreover, mortality rates across targeted and untargeted conditions were generally getting worse after the introduction of Medicare's P4P programs. Trends in PSIs were extremely mixed, with five outcomes trending in an expected (improving) direction, five trending in an unexpected (deteriorating) direction, and three with insignificant changes over time. Sensitivity analyses did not substantially alter these results. CONCLUSIONS: Consistent with previous studies for individual programs, we detect minimal, if any, effect of Medicare's hospital P4P programs on quality and safety. Given the growing evidence of limited impact, the administrative cost of monitoring and enforcing penalties, and potential increase in mortality, CMS should consider redesigning their P4P programs before continuing to expand them.

An examination of health care utilization during the COVID-19 pandemic among women with early-stage hormone receptor-positive breast cancer.

BACKGROUND: Women undergoing treatment for breast cancer require frequent clinic visits for maintenance of therapy. With COVID-19 causing health care disruptions, it is important to learn about how this population's access to health care has changed. This study compares self-reported health care utilization and changes in factors related to health care access among women treated at a cancer center in the mid-South US before and during the pandemic. METHODS: Participants (N = 306) part of a longitudinal study to improve adjuvant endocrine therapy (AET) adherence completed pre-intervention baseline surveys about their health care utilization prior to AET initiation. Questions about the impact of COVID-19 were added after the pandemic started assessing financial loss and factors related to care. Participants were categorized into three time periods based on the survey completion date: (1) pre-COVID (December 2018 to March 2020), (2) early COVID (April 2020 - December 2020), and later COVID (January 2021 to June 2021). Negative binomial regression analyses used to compare health care utilization at different phases of the pandemic controlling for patient characteristics. RESULTS: Adjusted analyses indicated office visits declined from pre-COVID, with an adjusted average of 17.7 visits, to 12.1 visits during the early COVID period (p = 0.01) and 9.9 visits during the later COVID period (p < 0.01). Hospitalizations declined from an adjusted average 0.45 admissions during early COVID to 0.21 during later COVID, after vaccines became available (p = 0.05). Among COVID period participants, the proportion reporting changes/gaps in health insurance coverage increased from 9.5% participants during early-COVID to 14.8% in the later-COVID period (p = 0.05). The proportion reporting financial loss due to the pandemic was similar during both COVID periods (34.3% early- and 37.7% later-COVID, p = 0.72). The proportion of participants reporting delaying care or refilling prescriptions decreased from 15.2% in early-COVID to 4.9% in the later-COVID period (p = 0.04). CONCLUSION: COVID-19 caused disruptions to routine health care for women with breast cancer. Patients reported having fewer office visits at the start of the pandemic that continued to decrease even after vaccines were available. Fewer patients reported delaying in-person care as the pandemic progressed.

Persistent polypharmacy and fall injury risk: the Health, Aging and Body Composition Study.

BACKGROUND: Older adults receive treatment for fall injuries in both inpatient and outpatient settings. The effect of persistent polypharmacy (i.e. using multiple medications over a long period) on fall injuries is understudied, particularly for outpatient injuries. We examined the association between persistent polypharmacy and treated fall injury risk from inpatient and outpatient settings in community-dwelling older adults. METHODS: The Health, Aging and Body Composition Study included 1764 community-dwelling adults (age 73.6 ± 2.9 years; 52% women; 38% black) with Medicare Fee-For-Service (FFS) claims at or within 6 months after 1998/99 clinic visit. Incident fall injuries (N = 545 in 4.6 ± 2.9 years) were defined as the initial claim with an ICD-9 fall E-code and non-fracture injury, or fracture code with/without a fall code from 1998/99 clinic visit to 12/31/08. Those without fall injury (N = 1219) were followed for 8.1 ± 2.6 years. Stepwise Cox models of fall injury risk with a time-varying variable for persistent polypharmacy (defined as ≥6 prescription medications at the two most recent consecutive clinic visits) were adjusted for demographics, lifestyle characteristics, chronic conditions, and functional ability. Sensitivity analyses explored if persistent polypharmacy both with and without fall risk increasing drugs (FRID) use were similarly associated with fall injury risk. RESULTS: Among 1764 participants, 636 (36%) had persistent polypharmacy over the follow-up period, and 1128 (64%) did not. Fall injury incidence was 38 per 1000 person-years. Persistent polypharmacy increased fall injury risk (hazard ratio [HR]: 1.31 [1.06, 1.63]) after adjusting for covariates. Persistent polypharmacy with FRID use was associated with a 48% increase in fall injury risk (95%CI: 1.10, 2.00) vs. those who had non-persistent polypharmacy without FRID use. Risks for persistent polypharmacy without FRID use (HR: 1.22 [0.93, 1.60]) and non-persistent polypharmacy with FRID use (HR: 1.08 [0.77, 1.51]) did not significantly increase compared to non-persistent polypharmacy without FRID use. CONCLUSIONS: Persistent polypharmacy, particularly combined with FRID use, was associated with increased risk for treated fall injuries from inpatient and outpatient settings. Clinicians may need to consider medication management for FRID and other fall prevention strategies in community-dwelling older adults with persistent polypharmacy to reduce fall injury risk.

Measurement matters: changing penalty calculations under the hospital acquired condition reduction program (HACRP) cost hospitals millions.

BACKGROUND: Since October 2014, the Centers for Medicare and Medicaid Services has penalized 25% of U.S. hospitals with the highest rates of hospital-acquired conditions under the Hospital Acquired Conditions Reduction Program (HACRP). While early evaluations of the HACRP program reported cumulative reductions in hospital-acquired conditions, more recent studies have not found a clear association between receipt of the HACRP penalty and hospital quality of care. We posit that some of this disconnect may be driven by frequent scoring updates. The sensitivity of the HACRP penalties to updates in the program's scoring methodology has not been independently evaluated. METHODS: We used hospital discharge records from 14 states to evaluate the association between changes in HACRP scoring methodology and corresponding shifts in penalty status. To isolate the impact of changes in scoring methods over time, we used FY2018 hospital performance data to calculate total HAC scores using FY2015 through FY2018 CMS scoring methodologies. RESULTS: Comparing hospital penalty status based on various HACRP scoring methodologies over time, we found a significant overlap between penalized hospitals when using FY 2015 and 2016 scoring methodologies (95%) and between FY 2017 and 2018 methodologies (46%), but substantial differences across early vs later years. Only 15% of hospitals were eligible for penalties across all four years. We also found significant changes in a hospital's (relative) ranking across the various years, indicating that shifts in penalty status were not driven by small changes in HAC scores clustered around the penalty threshold. CONCLUSIONS: HACRP penalties have been highly sensitive to program updates, which are generally announced after performance periods are concluded. This disconnect between performance and penalties calls into question the ability of the HACRP to improve patient safety as intended.

"Nobody Will Tell You. You've Got to Ask!": An Examination of Patient-Provider Communication Needs and Preferences among Black and White Women with Early-Stage Breast Cancer.

Patient-provider communication is a critical component of healthcare and is associated with treatment quality and outcomes for women with breast cancer. This qualitative study examines similarities and differences in patient perspectives of communication needs between Black and White breast cancer survivors. We conducted four focus groups (N = 28) involving women with early-stage breast cancer on adjuvant endocrine therapy (AET), stratified by race and length of time on AET (< 6 months and >6 months). Each group was moderated by a race-concordant moderator and analyzed by emergent themes. Participants expressed common patient-provider communication needs, namely increased sensitivity from oncologists during the initial cancer diagnosis, personalized information to facilitate treatment decisions, emotional support during the transition from active treatment to maintenance, and rapid provider responses to mobile app-based queries. Communication differences by race also emerged. Black women were less likely than White women to describe having their informational needs met. White women praised longstanding relationships with providers, while Black women shared personal stories of disempowered interactions and noted the importance of patient advocates. White women more often reported privacy concerns about technology use. Unlike White women, Black women reported willingness to discuss sensitive topics, both online and offline, but believed those discussions made their providers feel uncomfortable. Early-stage breast cancer patients on AET, regardless of race, have similar needs for patient-centered communication with their oncologists. However, Black women were more likely to report experiencing poorer communication with providers than White women, which may be improved by technology and advocates.

How Have 30-Day Readmission Penalties Affected Racial Disparities in Readmissions?: an Analysis from 2007 to 2014 in Five US States.

BACKGROUND: Thirty-day readmission penalties implemented with the Hospital Readmission Reduction Program (HRRP) place a larger burden on safety-net hospitals which treat a disproportionate share of racial minorities, leading to concerns that already large racial disparities in readmissions could widen. OBJECTIVE: To examine whether there were changes in Black-White disparities in 30-day readmissions for acute myocardial infarction (AMI), congestive heart failure (CHF), or pneumonia following the passage and implementation of HRRP, and to compare disparities across safety-net and non-safety-net hospitals. DESIGN: Repeated cross-sectional analysis, stratified by safety-net status. SUBJECTS: 1,745,686 Medicare patients over 65 discharged alive from hospitals in 5 US states: NY, FL, NE, WA, and AR. MAIN MEASURES: Odds ratios comparing 30-day readmission rates following an index admission for AMI, CHF, or pneumonia for Black and White patients between 2007 and 2014. KEY RESULTS: Prior to the passage of HRRP in 2010, Black and White readmission rates and disparities in readmissions were decreasing. These reductions were largest at safety-net hospitals. In 2007, Blacks had 13% higher odds of readmission if treated in safety-net hospitals, compared with 5% higher odds in 2010 (P < 0.05). These trends continued following the passage of HRRP. CONCLUSIONS: Prior to HRRP, there were large reductions in Black-White disparities in readmissions at safety-net hospitals. Although HRRP tends to assess higher penalties for safety-net hospitals, improvements in readmissions have not reversed following the implementation of HRRP. In contrast, disparities continue to persist at non-safety-net hospitals which face much lower penalties.

Effect of Intensive Interdisciplinary Transitional Care for High-Need, High-Cost Patients on Quality, Outcomes, and Costs: a Quasi-Experimental Study.

BACKGROUND: Many health systems have implemented team-based programs to improve transitions from hospital to home for high-need, high-cost patients. While preliminary outcomes are promising, there is limited evidence regarding the most effective strategies. OBJECTIVE: To determine the effect of an intensive interdisciplinary transitional care program emphasizing medication adherence and rapid primary care follow-up for high-need, high-cost Medicaid and Medicare patients on quality, outcomes, and costs. DESIGN: Quasi-experimental study. PATIENTS: Among 2235 high-need, high-cost Medicare and Medicaid patients identified during an index inpatient hospitalization in a non-profit health care system in a medically underserved area with complete administrative claims data, 285 participants were enrolled in the SafeMed care transition intervention, and 1950 served as concurrent controls. INTERVENTIONS: The SafeMed team conducted hospital-based real-time screening, patient engagement, enrollment, enhanced discharge care coordination, and intensive home visits and telephone follow-up for at least 45 days. MAIN MEASURES: Primary difference-in-differences analyses examined changes in quality (primary care visits, and medication adherence), outcomes (preventable emergency visits and hospitalizations, overall emergency visits, hospitalizations, 30-day readmissions, and hospital days), and medical expenditures. KEY RESULTS: Adjusted difference-in-differences analyses demonstrated that SafeMed participation was associated with 7% fewer hospitalizations (- 0.40; 95% confidence interval (CI), - 0.73 to - 0.06), 31% fewer 30-day readmissions (- 0.34; 95% CI, - 0.61 to - 0.07), and reduced medical expenditures ($- 8690; 95% CI, $- 14,441 to $- 2939) over 6 months. Improvements were limited to Medicaid patients, who experienced large, statistically significant decreases of 39% in emergency department visits, 25% in hospitalizations, and 79% in 30-day readmissions. Medication adherence was unchanged (+ 2.6%; 95% CI, - 39.1% to 72.9%). CONCLUSIONS: Care transition models emphasizing strong interdisciplinary patient engagement and rapid primary care follow-up can enable health systems to improve quality and outcomes while reducing costs among high-need, high-cost Medicaid patients.

Evaluation of a Tennessee statewide initiative to reduce early elective deliveries using quasi-experimental methods.

BACKGROUND: Concerted quality improvement (QI) efforts have been taken to discourage the practice of early elective deliveries (EEDs), but few studies have robustly examined the impact of directed QI interventions in reducing EED practices. Using quasi-experimental methods, we sought to evaluate the impact of a statewide QI intervention to reduce the practice of EEDs. METHODS: Retrospective cohort study of vital records data (2007 to 2013) for all singleton births occurring ≥36 weeks in 66 Tennessee hospitals grouped into three QI cohorts. We used interrupted-time series to estimate the effect of the QI intervention on the likelihood of an EED birth statewide, and by hospital cohort. We compared the distribution of hospital EED percentages pre- and post-intervention. Lastly, we used multivariable logistic regression to estimate the effect of QI interventions on maternal and infant outcomes. RESULTS: Implementation of the QI intervention was associated with significant declines in likelihood of EEDs immediately following the intervention (odds ratio, OR = 0.72; p < 0.001), but these results varied by hospital cohort. Hospital risk-adjusted EED percentages ranged from 1.6-13.6% in the pre-intervention period, which significantly declined to 2.2-9.6% in the post-intervention period (p < 0.001). The QI intervention was also associated with significant reductions in operative vaginal delivery and perineal laceration, and immediate infant ventilation, but increased NICU admissions. CONCLUSIONS: A statewide QI intervention to reduce EEDs was associated with modest but significant declines in EEDs beyond concurrent and national trends, and showed mixed results in related infant and maternal outcomes.

THRIVE study protocol: a randomized controlled trial evaluating a web-based app and tailored messages to improve adherence to adjuvant endocrine therapy among women with breast cancer.

BACKGROUND: Long-term use of adjuvant endocrine therapy (AET) among women with early-stage, hormone receptor-positive breast cancer significantly reduces the risk of hospitalizations, cancer recurrence, and mortality. AET is associated with adverse symptoms that often result in poor adherence. A web-enabled app offers a novel way to communicate and manage symptoms for women on AET. In a region with significant racial disparities in breast cancer outcomes, our study tests the impact of a web-enabled app that collects and transmits patient-reported symptoms to healthcare teams to facilitate timely and responsive symptom management on medication adherence. METHODS: In this randomized controlled trial, we randomize 300 patients initiating AET to one of three arms: 1) an "App" group (n = 100) that receives weekly reminders to use the THRIVE study app; 2) an "App+Feedback" group (n = 100) that receives weekly reminders and tailored feedback based on their use of the app; or 3) a "Usual Care" group (n = 100) that receives usual care only. Participants are stratified by race: 50% White and 50% Black. The duration of the intervention is six months following enrollment, and outcomes are assessed at 12-months. The primary outcome is adherence, which is captured using an electronic monitoring pillbox. Secondary outcomes include symptom burden, quality of life, self-efficacy for managing symptoms, and healthcare costs. We also evaluate the impact of the intervention on racial disparities in adherence. Data are derived from three sources: electronic health record data to capture treatment changes, healthcare utilization, and health outcomes; self-report survey data related to adherence, symptom burden, and quality of life; and an electronic medication monitoring device that captures adherence. DISCUSSION: A successful web-enabled intervention could be disseminated across systems, conditions, and populations. By evaluating the impact of this intervention on a comprehensive set of measures, including AET adherence, patient outcomes, and costs, our study will provide valuable and actionable results for providers, policy makers, and insurers who strive to achieve the "Triple Aim" - reduce costs while improving health outcomes and the patient care experience. TRIAL REGISTRATION: NCT03592771. Prospectively registered on July 19, 2018.

Three years in - changing plan features in the U.S. health insurance marketplace.

BACKGROUND: A central objective of recent U.S. healthcare policy reform, most notably the Affordable Care Act's (ACA) Health Insurance Marketplace, has been to increase access to stable, affordable health insurance. However, changing market dynamics (rising premiums, changes in issuer participation and plan availability) raise significant concerns about the marketplaces' ability to provide a stable source of healthcare for Americans that rely on them. By looking at the effect of instability on changes in the consumer choice set, we can analyze potential incentives to switch plans among price-sensitive enrollees, which can then be used to inform policy going forward. METHODS: Data on health plan features for non-tobacco users in 2512 counties in 34 states participating in federally-facilitated exchanges from 2014 to 2016 was obtained from the Centers for Medicaid & Medicare Services. We examined how changes in individual plan features, including premiums, deductibles, issuers, and plan types, impact consumers who had purchased the lowest-cost silver or bronze plan in their county the previous year. We calculated the cost of staying in the same plan versus switching to another plan the following year, and analyzed how costs vary across geographic regions. RESULTS: In most counties in 2015 and 2016 (53.7 and 68.2%, respectively), the lowest-cost silver plan from the previous year was still available, but was no longer the cheapest plan. In these counties, consumers who switched to the new lowest-cost plan would pay less in monthly premiums on average, by $51.48 and $55.01, respectively, compared to staying in the same plan. Despite potential premium savings from switching, however, the majority would still pay higher average premiums compared to the previous year, and most would face higher deductibles and an increased probability of having to change provider networks. CONCLUSION: While the ACA has shown promise in expanding healthcare access, continued changes in the availability and affordability of health plans are likely to result in churning and switching among enrollees, which may have negative ramifications for their health going forward. Future healthcare policy reform should aim to stabilize marketplace dynamics in order to encourage greater care continuity and limit churning.

Characteristics of Hospital and Emergency Care Super-utilizers with Multiple Chronic Conditions.

BACKGROUND: Targeted care transitions programs may improve the value of hospital-based health care. Super-utilizing patients with multiple chronic conditions (MCC) are thought to be particularly amenable to care transitions interventions. OBJECTIVES: To identify characteristics, future utilization patterns, and health outcomes for super-utilizers with MCC. METHODS: Retrospective cohort study of patients receiving care in an urban multi-hospital system in Tennessee over 3 years. Adult patients with Medicaid or Medicare insurance, or both, MCC, and multiple hospitalizations and emergency department (ED) visits in a 6-month period were included. The primary outcome measures were numbers of hospitalizations and ED visits in the 12 months after the 6-month period of high utilization. Secondary outcomes included 30-day readmissions and discharge disposition. RESULTS: Of 1537 super-utilizing patients, 59.0% (n = 907) had at least two targeted chronic conditions. This final study cohort (n = 638) experienced a mean of 3.2 hospitalizations and 2.8 ED visits without hospitalization in the 12-month follow-up period. During follow-up, 26% experienced one or more 30-day readmission(s) within the health care system. Despite their medical complexity, 46% reported not having a regular primary care provider, and 48% had presenting pain scores ≥8/10. Only 1% of the visits to the ED were triaged as nonurgent. CONCLUSIONS: Medicare and Medicaid patients with high baseline utilization and MCC experience continued high health care utilization. Patient characteristics, future utilization patterns, and health outcomes suggest the subgroup identified is an important subgroup of super-utilizers that merits attention because they may be particularly amenable to intervention.

Tobacco Surcharges on 2015 Health Insurance Plans Sold in Federally Facilitated Marketplaces: Variations by Age and Geography and Implications for Health Equity.

In 2014, few health insurance plans sold in the Affordable Care Act's Federally Facilitated Marketplaces had age-dependent tobacco surcharges, possibly because of a system glitch. The 2015 tobacco surcharges show wide variation, with more plans implementing tobacco surcharges that increase with age. This underscores concerns that older tobacco users will find postsubsidy health insurance premiums difficult to afford. Future monitoring of enrollment will determine whether tobacco surcharges cause adverse selection by dissuading tobacco users, particularly older users, from buying health insurance.

The U.S. health insurance marketplace: are premiums truly affordable?

The Patient Protection and Affordable Care Act requires that individuals have health insurance or pay a penalty. Individuals are exempt from paying this penalty if the after-subsidy cost of the least-expensive plan available to them is greater than 8% of their income. For this study, premium data for all health plans offered on the state and federal health insurance marketplaces were collected; the after-subsidy cost of premiums for the least-expensive bronze plan for every county in the United States was calculated; and variations in premium affordability by age, income, and geographic area were assessed. Results indicated that-although marketplace subsidies ensure affordable health insurance for most persons in the United States-many individuals with incomes just above the subsidy threshold will lack affordable coverage and will be exempt from the mandate. Furthermore, young individuals with low incomes often pay as much as or more than older individuals for bronze plans. If substantial numbers of younger, healthier adults choose to remain uninsured because of cost, health insurance premiums across all ages may increase over time.

Economic return from the Women's Health Initiative estrogen plus progestin clinical trial: a modeling study.

BACKGROUND: The findings of the Women's Health Initiative (WHI) estrogen plus progestin (E+P) trial led to a substantial reduction in use of combined hormone therapy (cHT) among postmenopausal women in the United States. The economic effect of this shift has not been evaluated relative to the trial's $260 million cost (2012 U.S. dollars). OBJECTIVE: To estimate the economic return from the WHI E+P trial. DESIGN: Decision model to simulate health outcomes for a "WHI scenario" with observed cHT use and a "no-WHI scenario" with cHT use extrapolated from the pretrial period. DATA SOURCES: Primary analyses of WHI outcomes, peer-reviewed literature, and government sources. TARGET POPULATION: Postmenopausal women in the United States, aged 50 to 79 years, who did not have a hysterectomy. TIME HORIZON: 2003 to 2012. PERSPECTIVE: Payer. INTERVENTION: Combined hormone therapy. OUTCOME MEASURES: Disease incidence, expenditure, quality-adjusted life-years, and net economic return. RESULTS OF BASE-CASE ANALYSIS: The WHI scenario resulted in 4.3 million fewer cHT users, 126,000 fewer breast cancer cases, 76,000 fewer cardiovascular disease cases, 263,000 more fractures, 145,000 more quality-adjusted life-years, and expenditure savings of $35.2 billion. The corresponding net economic return of the trial was $37.1 billion ($140 per dollar invested in the trial) at a willingness-to-pay level of $100,000 per quality-adjusted life-year. RESULTS OF SENSITIVITY ANALYSIS: The 95% CI for the net economic return of the trial was $23.1 to $51.2 billion. LIMITATION: No evaluation of indirect costs or outcomes beyond 2012. CONCLUSION: The WHI E+P trial made high-value use of public funds with a substantial return on investment. These results can contribute to discussions about the role of public funding for large, prospective trials with high potential for public health effects. PRIMARY FUNDING SOURCE: National Heart, Lung, and Blood Institute.

The Impact of Prescription Drug Coverage on Disparities in Adherence and Medication Use: A Systematic Review.

Prescription drug cost-sharing is a barrier to medication adherence, particularly for low-income and minority populations. In this systematic review, we examined the impact of prescription drug cost-sharing and policies to reduce cost-sharing on racial/ethnic and income disparities in medication utilization. We screened 2,145 titles and abstracts and identified 19 peer-reviewed papers that examined the interaction between cost-sharing and racial/ethnic and income disparities in medication adherence or utilization. We found weak but inconsistent evidence that lower cost-sharing is associated with reduced disparities in adherence and utilization, but studies consistently found that significant disparities remained even after adjusting for differences in cost-sharing across individuals. Study designs varied in their ability to measure the causal effect of policy or cost-sharing changes on disparities, and a wide range of policies were examined across studies. Further research is needed to identify the types of policies that are best suited to reduce disparities in medication adherence.

Longitudinal Trends in Insurer Participation in Multisector Population Health Activities.

Healthcare organizations increasingly engage in activities to identify and address social determinants of health (SDOH) among their patients to improve health outcomes and reduce costs. While several studies to date have focused on the evolving role of hospitals and physicians in these types of population health activities, much less is known about the role health insurers may play. We used data from the National Longitudinal Survey of Public Health Systems for the period 2006 to 2018 to examine trends in health insurer participation in population health activities and in the multi-sector collaborative networks that support these activities. We also used a difference-in-differences approach to examine the impact of Medicaid expansion on insurer participation in population health networks. Insurer participation increased in our study period both in the delivery of population health activities and in the integration into collaborative networks that support these activities. Insurers were most likely to participate in activities focusing on community health assessment and policy development. Results from our adjusted difference-in-differences models showed variation in association between insurer participation in population health networks and Medicaid expansion (Table 2). Population health networks in expansion states experienced significant increases insurer participation in assessment (4.48 percentage points, P < .05) and policy and planning (7.66 percentage points, P < .05) activities. Encouraging insurance coverage gains through policy mechanisms like Medicaid expansion may not only improve access to healthcare services but can also act as a driver of insurer integration into population health networks.

Association Between Community Social Vulnerability and Preventable Hospitalizations.

Preventable hospitalizations are common and costly events that burden patients and our health care system. While research suggests that these events are strongly linked to ambulatory care access, emerging evidence suggests they may also be sensitive to a patient's social, environmental, and economic conditions. This study examines the association between variations in social vulnerability and preventable hospitalization rates. We conducted a cross-sectional analysis of county-level preventable hospitalization rates for 33 states linked with data from the 2020 Social Vulnerability Index (SVI). Preventable hospitalizations were 40% higher in the most vulnerable counties compared with the least vulnerable. Adjusted regression results confirm the strong relationship between social vulnerability and preventable hospitalizations. Our results suggest wide variation in community-level preventable hospitalization rates, with robust evidence that variation is strongly related to a community's social vulnerability. The human toll, societal cost, and preventability of these hospitalizations make understanding and mitigating these inequities a national priority.

Overweight/obesity, gestational weight gain, postpartum weight retention, and maternal/neonatal complications in the military.

OBJECTIVE: The objective of this study was to examine the prevalence of overweight/obesity and excessive gestational weight gain (GWG) among military beneficiaries and to assess associations of these risk factors with maternal/neonatal complications and substantial postpartum weight retention (PPWR). METHODS: We obtained data for 48,391 TRICARE beneficiaries who gave birth in 2018 or 2019 in the United States. We used logistic regression and ANOVA to examine relationships among overweight/obesity, GWG, maternal/neonatal complications, and substantial PPWR. RESULTS: Most TRICARE beneficiaries (75%) had excessive GWG, and 42% had substantial PPWR. Dependents were less likely than active-duty women to have excessive GWG (odds ratio [OR] = 0.73, 95% CI: 0.60-0.88). Women with excessive GWG were three times more likely to have substantial PPWR (OR = 3.57, 95% CI: 3.14-4.06). Those with excessive GWG were more likely to have maternal/neonatal complications (e.g., pregnancy-induced hypertension, cesarean delivery). CONCLUSIONS: Excessive GWG is frequent among TRICARE beneficiaries, particularly active-duty personnel, and is strongly associated with costly maternal/neonatal complications. Substantial PPWR is also common in this population, with excessive GWG as a key risk factor.