Protecting Patients And Society In An Era Of Private Equity Provider Ownership: Challenges And Opportunities For Policy.

Private equity (PE) acquisitions in health care delivery nearly tripled from 2010 to 2020. Despite concerns around clinical and economic implications, policy responses have remained limited. We discuss the US policy landscape around PE ownership, using policies in the European Union for comparison. We present four domains in which policy can be strengthened. First, to improve oversight of acquisitions, policy makers should lower reporting thresholds, review sequential acquisitions that together affect market power, automate reviews with potential denials based on market concentration effects, consider new regulatory mechanisms such as attorney general veto, and increase funding for this work. Second, policy makers should increase the longer-run transparency of PE ownership, including the health care prices garnered by acquired entities. Third, policy makers should protect patients and providers by establishing minimum staffing ratios, spending floors for direct patient care, and limits on layoffs and the sale of real estate after acquisition (forms of "asset stripping"). Finally, policy makers should mitigate risky financial behavior by limiting the amount or proportion of debt used to finance PE acquisitions in health care.

Surprise billing in intensive care unit (ICU) hospitalizations.

Intensive care unit (ICU) care is expensive for patients and providers, and utilization and spending on ICU resources have increased. The No Surprises Act, passed in 2022, specifically prohibits balance billing by ICU specialists (intensivists) for emergency and most non-emergency care. The potential economic impact of this remains unclear, given few data exist on the magnitude of balance billing in the ICU. Using the MarketScan Commercial (IBM) database, we studied hospitalizations in which ICU care was provided ("ICU hospitalizations") between 2010 and 2019. Hospitalizations were characterized as fully in-network, fully out-of-network, or "mixed" (contained both in- and out-of-network services). The share of "mixed" hospitalizations among all ICU hospitalizations rose from 26% to 33% over the study period. Over half of these mixed hospitalizations contained out-of-network services specifically delivered within the ICU. Total hospitalization spending averaged $81 047, with ICU spending averaging $15 799. On average, 11% of ICU spending within these hospitalizations was out-of-network. Patients were plausibly balance-billed in approximately one-third of ICU hospitalizations, for thousands of dollars per hospitalization. Given that the No Surprises Act prevents this type of balance billing, the portended revenue loss may lead to changes in provider negotiations with insurers concerning network status and prices, which could affect the care patients receive.

The New Role of Private Investment in Health Care Delivery.

This JAMA Forum discusses the good and bad of innovation in health care delivery, tax policy, an escrow account for failure, and state monitoring.

Private Equity and Cardiovascular Health Care.

This Viewpoint discusses involvement of private equity firms in health care.

Increases in Medicare Spending and Use after Private Equity Acquisition of Retina Practices.

PURPOSE: Private equity (PE) firms increasingly are acquiring physician practices in the United States, particularly within procedural-based specialties such as ophthalmology including retina. To date, the potential impact of ophthalmology practice acquisitions remains unknown. We evaluated the association between PE acquisition and Medicare spending and use for common retina services. DESIGN: Retrospective difference-in-differences analysis using the 20% Medicare fee-for-service claims dataset from January 1, 2015, through December 31, 2019. PARTICIPANTS: Eighty-two practices acquired by PE during the study period and matched control practices. METHODS: We used novel data on PE acquisitions of retina practices linked to the 20% sample Medicare claims data. Retina practices acquired by PE between 2016 and 2019 were matched to up to 3 non-PE (control) practices based on characteristics before acquisition. Private equity-acquired practices were compared with matched control practices through 6 quarters after acquisition using a difference-in-differences event study design. Data analyses were performed between August 2022 and April 2023. MAIN OUTCOME MEASURES: Medicare spending and use of common retina services. RESULTS: Relative to control practices, PE-acquired retina practices increased the use of higher-priced anti-vascular endothelial growth factor (VEGF) agents including aflibercept, which differentially increased by 6.5 injections (95% confidence interval, 0.4-12.5; P = 0.03) per practice-quarter, or 22% from baseline. As a result, Medicare spending on aflibercept differentially increased by $13 028 per practice-quarter, or 21%. No statistically significant differences were found in use or spending for evaluation and management visits or diagnostic imaging. CONCLUSIONS: Private equity acquisition of retina practices are associated with modest increases in the use of higher-priced anti-VEGF drugs like aflibercept, leading to higher Medicare spending. This finding highlights the need to monitor the influence of PE firms' financial incentives over clinician decision-making and the appropriateness of care, which could be swayed by strong economic incentives. FINANCIAL DISCLOSURE(S): Proprietary or commercial disclosure may be found in the Footnotes and Disclosures at the end of this article.

Changes in Hospital Adverse Events and Patient Outcomes Associated With Private Equity Acquisition.

Importance: The effects of private equity acquisitions of US hospitals on the clinical quality of inpatient care and patient outcomes remain largely unknown. Objective: To examine changes in hospital-acquired adverse events and hospitalization outcomes associated with private equity acquisitions of US hospitals. Design, Setting, and Participants: Data from 100% Medicare Part A claims for 662 095 hospitalizations at 51 private equity-acquired hospitals were compared with data for 4 160 720 hospitalizations at 259 matched control hospitals (not acquired by private equity) for hospital stays between 2009 and 2019. An event study, difference-in-differences design was used to assess hospitalizations from 3 years before to 3 years after private equity acquisition using a linear model that was adjusted for patient and hospital attributes. Main Outcomes and Measures: Hospital-acquired adverse events (synonymous with hospital-acquired conditions; the individual conditions were defined by the US Centers for Medicare & Medicaid Services as falls, infections, and other adverse events), patient mix, and hospitalization outcomes (including mortality, discharge disposition, length of stay, and readmissions). Results: Hospital-acquired adverse events (or conditions) were observed within 10 091 hospitalizations. After private equity acquisition, Medicare beneficiaries admitted to private equity hospitals experienced a 25.4% increase in hospital-acquired conditions compared with those treated at control hospitals (4.6 [95% CI, 2.0-7.2] additional hospital-acquired conditions per 10 000 hospitalizations, P = .004). This increase in hospital-acquired conditions was driven by a 27.3% increase in falls (P = .02) and a 37.7% increase in central line-associated bloodstream infections (P = .04) at private equity hospitals, despite placing 16.2% fewer central lines. Surgical site infections doubled from 10.8 to 21.6 per 10 000 hospitalizations at private equity hospitals despite an 8.1% reduction in surgical volume; meanwhile, such infections decreased at control hospitals, though statistical precision of the between-group comparison was limited by the smaller sample size of surgical hospitalizations. Compared with Medicare beneficiaries treated at control hospitals, those treated at private equity hospitals were modestly younger, less likely to be dually eligible for Medicare and Medicaid, and more often transferred to other acute care hospitals after shorter lengths of stay. In-hospital mortality (n = 162 652 in the population or 3.4% on average) decreased slightly at private equity hospitals compared with the control hospitals; there was no differential change in mortality by 30 days after hospital discharge. Conclusions and Relevance: Private equity acquisition was associated with increased hospital-acquired adverse events, including falls and central line-associated bloodstream infections, along with a larger but less statistically precise increase in surgical site infections. Shifts in patient mix toward younger and fewer dually eligible beneficiaries admitted and increased transfers to other hospitals may explain the small decrease in in-hospital mortality at private equity hospitals relative to the control hospitals, which was no longer evident 30 days after discharge. These findings heighten concerns about the implications of private equity on health care delivery.

Firearm Injuries In Children And Adolescents: Health And Economic Consequences Among Survivors And Family Members.

More US children and adolescents today die from firearms than any other cause, and many more sustain firearm injuries and survive. The clinical and economic impact of these firearm injuries on survivors and family members remains poorly understood. Using 2007-21 commercial health insurance claims data, we studied 2,052 child and adolescent survivors compared to 9,983 matched controls who did not incur firearm injuries, along with 6,209 family members of survivors compared to 29,877 matched controls, and 265 family members of decedents compared to 1,263 matched controls. Through one year after firearm injury, child and adolescent survivors experienced a 117 percent increase in pain disorders, a 68 percent increase in psychiatric disorders, and a 144 percent increase in substance use disorders relative to the controls. Survivors' health care spending increased by an average of $34,884-a 17.1-fold increase-with 95 percent paid by insurers or employers. Parents of survivors experienced a 30-31 percent increase in psychiatric disorders, with 75 percent more mental health visits by mothers, and 5-14 percent reductions in mothers' and siblings' routine medical care. Family members of decedents experienced substantially larger 2.3- to 5.3-fold increases in psychiatric disorders, with at least 15.3-fold more mental health visits among parents. Firearm injuries in youth have notable health implications for the whole family, along with large effects on societal spending.

Growth In Patient Cost Sharing For Hospitalizations With And Without Intensive Care Among Commercially Insured Patients.

Intensive care units (ICUs) are increasingly used for hospital care, yet out-of-pocket spending for ICU hospitalizations remains poorly understood, particularly among the nearly half of the US population with commercial health insurance. Using 2008-19 MarketScan data, we compared 1,441,810 hospitalizations involving ICU services with 13,011,208 hospitalizations that did not involve ICU services. Average cost sharing, adjusted for patient and admission factors, increased from $1,137 per hospitalization in 2008 to $1,539 in 2019, or a 34 percent increase. This was driven by increasing deductibles, which rose by 163 percent. Across twenty clinical conditions whose hospitalizations commonly occurred in both ICU and non-ICU settings, ICU admission was associated with $155 higher cost sharing (13.0 percent higher) relative to cost sharing in non-ICU hospitalizations. Patients with high-deductible plans faced the highest cost sharing relative to those with other plan types. Patients who received out-of-network hospital care encountered higher cost sharing relative to those admitted to in-network hospitals with in-network clinicians.

Reconstructing Hydrogen Bond Network Enables High Voltage Aqueous Zinc-Ion Supercapacitors.

High-voltage aqueous rechargeable energy storage devices with safety and high specific energy are hopeful candidates for the future energy storage system. However, the electrochemical stability window of aqueous electrolytes is a great challenge. Herein, inspired by density functional theory (DFT), polyethylene glycol (PEG) can interact strongly with water molecules, effectively reconstructing the hydrogen bond network. In addition, N, N-dimethylformamide (DMF) can coordinate with Zn2+ , assisting in the rapid desolvation of Zn2+ and stable plating/stripping process. Remarkably, by introducing PEG400 and DMF as co-solvents into the electrolyte, a wide electrochemical window of 4.27 V can be achieved. The shift in spectra indicate the transformation in the number and strength of hydrogen bonds, verifying the reconstruction of hydrogen bond network, which can largely inhibit the activity of water molecule, according well with the molecular dynamics simulations (MD) and online electrochemical mass spectroscopy (OEMS). Based on this electrolyte, symmetric Zn cells survived up to 5000 h at 1 mA cm-2 , and high voltage aqueous zinc ion supercapacitors assembled with Zn anode and activated carbon cathode achieved 800 cycles at 0.1 A g-1 . This work provides a feasible approach for constructing high-voltage alkali metal ion supercapacitors through reconstruction strategy of hydrogen bond network.

Evidence for Anchoring Bias During Physician Decision-Making.

Introduction: Cognitive biases are hypothesized to influence physician decision-making, but large-scale evidence consistent with their influence is limited. One such bias is anchoring bias, or the focus on a single-often initial-piece of information when making clinical decisions without sufficiently adjusting to later information. Objective: To examine whether physicians were less likely to test patients with congestive heart failure (CHF) presenting to the emergency department (ED) with shortness of breath (SOB) for pulmonary embolism (PE) when the patient visit reason section, documented in triage before physicians see the patient, mentioned CHF. Design, Setting, and Participants: In this cross-sectional study of 2011 to 2018 national Veterans Affairs data, patients with CHF presenting with SOB in Veterans Affairs EDs were included in the analysis. Analyses were performed from July 2019 to January 2023. Exposure: The patient visit reason section, documented in triage before physicians see the patient, mentions CHF. Main Outcomes and Measures: The main outcomes were testing for PE (D-dimer, computed tomography scan of the chest with contrast, ventilation/perfusion scan, lower-extremity ultrasonography), time to PE testing (among those tested for PE), B-type natriuretic peptide (BNP) testing, acute PE diagnosed in the ED, and acute PE ultimately diagnosed (within 30 days of ED visit). Results: The present sample included 108 019 patients (mean [SD] age, 71.9 [10.8] years; 2.5% female) with CHF presenting with SOB, 4.1% of whom had mention of CHF in the patient visit reason section of the triage documentation. Overall, 13.2% of patients received PE testing, on average within 76 minutes, 71.4% received BNP testing, 0.23% were diagnosed with acute PE in the ED, and 1.1% were ultimately diagnosed with acute PE. In adjusted analyses, mention of CHF was associated with a 4.6 percentage point (pp) reduction (95% CI, -5.7 to -3.5 pp) in PE testing, 15.5 more minutes (95% CI, 5.7-25.3 minutes) to PE testing, and 6.9 pp (95% CI, 4.3-9.4 pp) more BNP testing. Mention of CHF was associated with a 0.15 pp lower (95% CI, -0.23 to -0.08 pp) likelihood of PE diagnosis in the ED, although no significant association between the mention of CHF and ultimately diagnosed PE was observed (0.06 pp difference; 95% CI, -0.23 to 0.36 pp). Conclusions and Relevance: In this cross-sectional study among patients with CHF presenting with SOB, physicians were less likely to test for PE when the patient visit reason that was documented before they saw the patient mentioned CHF. Physicians may anchor on such initial information in decision-making, which in this case was associated with delayed workup and diagnosis of PE.

Changes in Prescription Drug and Health Care Use Over 9 Years After the Large Drug Price Increase for Colchicine.

Importance: Prescription drug prices are a leading concern among patients and policy makers. There have been large and sharp price increases for some drugs, but the long-term implications of large drug price increases remain poorly understood. Objective: To examine the association of the large 2010 price increase in colchicine, a common treatment for gout, with long-term changes in colchicine use, substitution with other drugs, and health care use. Design, Setting, and Participants: This retrospective cohort study examined MarketScan data from a longitudinal cohort of patients with gout with employer-sponsored insurance from 2007 through 2019. Exposures: The US Food and Drug Administration's discontinuation of lower-priced versions of colchicine from the market in 2010. Main Outcomes and Measures: Mean price of colchicine; use of colchicine, allopurinol, and oral corticosteroids; and emergency department (ED) and rheumatology visits for gout in year 1 and over the first decade of the policy (through 2019) were calculated. Data were analyzed between November 16, 2021, and January 17, 2023. Results: A total of 2 723 327 patient-year observations were examined from 2007 through 2019 (mean [SD] age of patients, 57.0 [13.8] years; 20.9% documented as female; 79.1% documented as male). The mean price per prescription of colchicine increased sharply from $11.25 (95% CI, $11.23-$11.28) in 2009 to $190.49 (95% CI, $190.07-$190.91) in 2011, a 15.9-fold increase, with the mean out-of-pocket price increasing 4.4-fold from $7.37 (95% CI, $7.37-$7.38) to $39.49 (95% CI, $39.42-$39.56). At the same time, colchicine use declined from 35.0 (95% CI, 34.6-35.5) to 27.3 (95% CI, 26.9-27.6) pills per patient in year 1 and to 22.6 (95% CI, 22.2-23.0) pills per patient in 2019. Adjusted analyses showed a 16.7% reduction in year 1 and a 27.0% reduction over the decade (P < .001). Meanwhile, adjusted allopurinol use rose by 7.8 (95% CI, 6.9-8.7) pills per patient in year 1, a 7.6% increase from baseline, and by 33.1 (95% CI, 32.6-33.7) pills per patient through 2019, a 32.0% increase from baseline over the decade (P < .001). Moreover, adjusted oral corticosteroid use exhibited no significant change in the first year, then increased by 1.5 (95% CI, 1.3-1.7) pills per patient through 2019, an 8.3% increase from baseline over the decade. Adjusted ED visits for gout rose by 0.02 (95% CI, 0.02-0.03) per patient in year 1, a 21.5% increase, and by 0.05 (95% CI, 0.04-0.05) per patient through 2019, a 39.8% increase over the decade (P < .001). Adjusted rheumatology visits for gout increased by 0.02 (95% CI, 0.02-0.03) per patient through 2019, a 10.5% increase over the decade (P < .001). Conclusions and Relevance: In this cohort study among individuals with gout, the large increase in colchicine prices in 2010 was associated with an immediate decrease in colchicine use that persisted over approximately a decade. Substitution with allopurinol and oral corticosteroids was also evident. Increased ED and rheumatology visits for gout over the same period suggest poorer disease control.

Changes in Out-of-Pocket Costs for US Hospital Admissions Between December and January Every Year.

This cross-sectional study examines cost-sharing for ICU and non-ICU hospitalizations among adults with employer-sponsored insurance.

Health Care Utilization among Homeless-Experienced Adults Who Were Seen by a Mobile Addiction Health Clinic in Boston, Massachusetts: A Quasi-Experimental Study.

Background: Mobile health clinics improve access to care for marginalized individuals who are disengaged from the healthcare system. This study evaluated the association between a mobile addiction health clinic and health care utilization among people experiencing homelessness. Methods: Using Medicaid claims data, we evaluated adults who were seen by a mobile addiction health clinic in Boston, Massachusetts from 1/16/18-1/15/19 relative to a propensity score matched control cohort. We evaluated both cohorts from four years before to one year after the index visit date with the mobile clinic. The primary outcome was the number of outpatient visits; secondary outcomes were the number of hospitalizations and emergency department (ED) visits. We used Poisson regression to compare changes in outcomes from before to after the index date in a quasi-experimental design. Results: 138 adults were seen by the mobile clinic during the observation period; 29.7% were female, 16.7% were Black, 8.0% Hispanic, 68.1% White, and the mean age was 40.4 years. The mean number of mobile clinic encounters was 3.1. The yearly mean number of outpatient visits increased from 11.5 to 12.1 (p = 0.43; pdiff-in-diff = 0.15), the number of hospitalizations increased from 2.2 to 3.0 (p = 0.04; pdiff-in-diff = 0.87), and the number of ED visits increased from 5.4 to 6.5 (p = 0.04; pdiff-in-diff = 0.40). Conclusions: The mobile addiction health clinic was not associated with statistically significant changes in health care utilization in the first year. Further research in larger samples using a broader set of outcomes is needed to quantify the benefits of this innovative care delivery model.

A Policy Framework for the Growing Influence of Private Equity in Health Care Delivery.

This Viewpoint details how and why improved oversight of private equity acquisition of physician practices and hospitals is needed to mitigate the effects on health care costs, clinicians' jobs, and patients' access to care.

Demographic And Clinical Factors Associated With Long COVID.

Risk factors for postacute sequelae of SARS-CoV-2 infection ("long COVID") in community-dwelling populations remain poorly understood. Large-scale data, follow-up, comparison groups, and a consensus definition of long COVID are often lacking. Using data from the OptumLabs Data Warehouse on a nationwide sample of commercial and Medicare Advantage enrollees from the period January 2019 through March 2022, we examined demographic and clinical factors associated with long COVID, using two definitions of people who suffer symptoms long after they were first diagnosed with COVID-19 ("long haulers"). We identified 8,329 long haulers using the narrow definition (diagnosis code), 207,537 long haulers using the broad definition (symptom based), and 600,161 non-long haulers (comparison group). On average, long haulers were older and more likely female, with more comorbidities. Among narrow-definition long haulers, the leading risk factors for long COVID included hypertension, chronic lung disease, obesity, diabetes, and depression. Their time between initial COVID-19 diagnosis and diagnosis of long COVID averaged 250 days, with racial and ethnic differences. Broad-definition long haulers exhibited similar risk factors. Distinguishing long COVID from the progression of underlying conditions can be challenging, but further study may advance the evidence base related to the identification, causes, and consequences of long COVID.