Cancer Screening after the Adoption of Paid-Sick-Leave Mandates.

BACKGROUND: By the end of 2022, nearly 20 million workers in the United States have gained paid-sick-leave coverage from mandates that require employers to provide benefits to qualified workers, including paid time off for the use of preventive services. Although the lack of paid-sick-leave coverage may hinder access to preventive care, current evidence is insufficient to draw meaningful conclusions about its relationship to cancer screening. METHODS: We examined the association between paid-sick-leave mandates and screening for breast and colorectal cancers by comparing changes in 12- and 24-month rates of colorectal-cancer screening and mammography between workers residing in metropolitan statistical areas (MSAs) that have been affected by paid-sick-leave mandates (exposed MSAs) and workers residing in unexposed MSAs. The comparisons were conducted with the use of administrative medical-claims data for approximately 2 million private-sector employees from 2012 through 2019. RESULTS: Paid-sick-leave mandates were present in 61 MSAs in our sample. Screening rates were similar in the exposed and unexposed MSAs before mandate adoption. In the adjusted analysis, cancer-screening rates were higher among workers residing in exposed MSAs than among those in unexposed MSAs by 1.31 percentage points (95% confidence interval [CI], 0.28 to 2.34) for 12-month colorectal cancer screening, 1.56 percentage points (95% CI, 0.33 to 2.79) for 24-month colorectal cancer screening, 1.22 percentage points (95% CI, -0.20 to 2.64) for 12-month mammography, and 2.07 percentage points (95% CI, 0.15 to 3.99) for 24-month mammography. CONCLUSIONS: In a sample of private-sector workers in the United States, cancer-screening rates were higher among those residing in MSAs exposed to paid-sick-leave mandates than among those residing in unexposed MSAs. Our results suggest that a lack of paid-sick-leave coverage presents a barrier to cancer screening. (Funded by the National Cancer Institute.).

Willingness to pay for private health insurance among workers with mandatory social health insurance in Mongolia.

BACKGROUND: High out-of-pocket health expenditure is a common problem in developing countries. The employed population, rather than the general population, can be considered the main contributor to healthcare financing in many developing countries. We investigated the feasibility of a parallel private health insurance package for the working population in Ulaanbaatar as a means toward universal health coverage in Mongolia. METHODS: This cross-sectional study used a purposive sampling method to collect primary data from workers in public and primary sectors in Ulaanbaatar. Willingness to pay (WTP) was evaluated using a contingent valuation method and a double-bounded dichotomous choice elicitation questionnaire. A final sample of 1657 workers was analyzed. Perceptions of current social health insurance were evaluated. To analyze WTP, we performed a 2-part model and computed the full marginal effects using both intensive and extensive margins. Disparities in WTP stratified by industry and gender were analyzed. RESULTS: Only < 40% of the participants were satisfied with the current mandatory social health insurance in Mongolia. Low quality of service was a major source of dissatisfaction. The predicted WTP for the parallel private health insurance for men and women was Mongolian Tugrik (₮)16,369 (p < 0.001) and ₮16,661 (p < 0.001), respectively, accounting for approximately 2.4% of the median or 1.7% of the average salary in the country. The highest predicted WTP was found for workers from the education industry (₮22,675, SE = 3346). Income and past or current medical expenditures were significantly associated with WTP. CONCLUSION: To reduce out-of-pocket health expenditure among the working population in Ulaanbaatar, Mongolia, supplementary parallel health insurance is feasible given the predicted WTP. However, given high variations among different industries and sectors, different incentives may be required for participation.

Fertility-a human right worthy of mandated insurance coverage: the evolution, limitations, and future of access to care.

We review the history, current status, and potential future of state infertility mandates and focus on the business implications of mandates and on the inadequacies and reproductive injustice resulting from gaps between legislative intent and practical implementation. Nineteen states have passed laws that require insurers to either cover or offer coverage for infertility diagnoses and treatment. The qualifications for coverage, extent of coverage, and exemptions vary drastically from one state to another, resulting in deficiencies in access to care even within mandated states for certain groups, such as single individuals, patients in same-sex relationships, and patients pursuing fertility preservation. Although insurance coverage of fertility services in the United States has expanded as an increasing number of states have enacted infertility mandates, significant gaps in implementation and access remain even among states with existing mandates. Provider, patient, and legislative advocacy is warranted in the name of reproductive justice to expand insurance coverage and, in turn, maximize reproductive outcomes, which have been shown to improve as financial barriers are lifted.

[Characteristics of compulsory service programs for medical professionals in the Andean states]. / Características del servicio social para profesionales médicos en los estados andinos.

INTRODUCTION: There are few studies on the impact of social service programs on health in the professional development of doctors in the Andean States (Argentina, Bolivia, Chile, Colombia, Ecuador, Peru, and Venezuela). The purpose of these programs is to increase the availability of human resources in health in rural and remote areas. OBJECTIVE: To describe the regulations of social service programs for medical professionals in the Andean countries. METHODS: We carried out a bibliographic review of normative documents concerning the social service for medical professionals using websites of governments of the Andean States as data sources. We sought to obtain information regarding service conditions, funding of these programsincluding remunerations, and means of program allocation. Additionally, we used PubMed/MEDLINE to find complementary information on mandatory social services in these countries. RESULTS: Social service for medical professionals is established under a regulatory framework in all the Andean countries, except for Argentina, where this program does not exist. Participants receive remuneration (except in Bolivia, where students perform the service). The allocation systems used for these programs are heterogeneous, and in some Andean countries, the allocation is merit-based. Participation in social programs influences later professional opportunities (Ecuador, Colombia, and Venezuela) and the ability to specialize (Chile and Peru). CONCLUSIONS: It is necessary to study the impact of these programs on the professional development of the participants to design and implement quality improvement strategies tailored to each context.

INTRODUCCIÓN: Se ha estudiado poco sobre el impacto de los programas de servicio social en salud en el desarrollo profesional de médicos de los Estados Andinos (Argentina, Bolivia, Chile, Colombia, Ecuador, Perú y Venezuela), programas cuya finalidad es incrementar los recursos humanos en salud en zonas rurales y remotas. OBJETIVO: Describir la normativa de los programas de servicio social para profesionales médicos de los Estados Andinos. MÉTODOS: Se realizó una revisión bibliográfica de documentos normativos concernientes al servicio social para profesionales médicos en sitios web de gobiernos de los Estados Andinos, con la finalidad de obtener información la condición de servicio, financiamiento del programa/remuneraciones y modos de adjudicación. Adicionalmente, se empleó el motor de búsqueda PubMed para complementar la información sobre servicios sociales obligatorios en estos países. RESULTADOS: El servicio social para profesionales médicos está establecido bajo un marco normativo en todos los Estados Andinos, a excepción de Argentina, donde no existe este programa. Los participantes perciben una remuneración, salvo en Bolivia, donde el servicio es realizado por estudiantes. Los sistemas de adjudicación para estos programas son heterogéneos, siendo que en algunos Estados Andinos existe asignación de plazas según criterios meritocráticos. La participación en programas sociales en salud condiciona el ejercicio profesional (Ecuador, Colombia y Venezuela) y el poder realizar una especialización (Chile y Perú). CONCLUSIONES: Se requiere estudiar del impacto de estos programas en el desarrollo profesional del participante, con el objetivo de implementar estrategias de mejora adecuadas a sus contextos particulares.

Características del servicio social para profesionales médicos en los estados andinos / Characteristics of compulsory service programs for medical professionals in the Andean states

INTRODUCCIÓN: Se ha estudiado poco sobre el impacto de los programas de servicio social en salud en el desarrollo profesional de médicos de los Estados Andinos (Argentina, Bolivia, Chile, Colombia, Ecuador, Perú y Venezuela), programas cuya finalidad es incrementar los recursos humanos en salud en zonas rurales y remotas. OBJETIVO: Describir la normativa de los programas de servicio social para profesionales médicos de los Estados Andinos. MÉTODOS: Se realizó una revisión bibliográfica de documentos normativos concernientes al servicio social para profesionales médicos en sitios web de gobiernos de los Estados Andinos, con la finalidad de obtener información la condición de servicio, financiamiento del programa/remuneraciones y modos de adjudicación. Adicionalmente, se empleó el motor de búsqueda PubMed para complementar la información sobre servicios sociales obligatorios en estos países. RESULTADOS: El servicio social para profesionales médicos está establecido bajo un marco normativo en todos los Estados Andinos, a excepción de Argentina, donde no existe este programa. Los participantes perciben una remuneración, salvo en Bolivia, donde el servicio es realizado por estudiantes. Los sistemas de adjudicación para estos programas son heterogéneos, siendo que en algunos Estados Andinos existe asignación de plazas según criterios meritocráticos. La participación en programas sociales en salud condiciona el ejercicio profesional (Ecuador, Colombia y Venezuela) y el poder realizar una especialización (Chile y Perú). CONCLUSIONES: Se requiere estudiar del impacto de estos programas en el desarrollo profesional del participante, con el objetivo de implementar estrategias de mejora adecuadas a sus contextos particulares.

INTRODUCTION: There are few studies on the impact of social service programs on health in the professional development of doctors in the Andean States (Argentina, Bolivia, Chile, Colombia, Ecuador, Peru, and Venezuela). The purpose of these programs is to increase the availability of human resources in health in rural and remote areas. OBJECTIVE: To describe the regulations of social service programs for medical professionals in the Andean countries. METHODS: We carried out a bibliographic review of normative documents concerning the social service for medical professionals using websites of governments of the Andean States as data sources. We sought to obtain information regarding service conditions, funding of these programs­including remunerations, and means of program allocation. Additionally, we used PubMed/MEDLINE to find complementary information on mandatory social services in these countries. RESULTS: Social service for medical professionals is established under a regulatory framework in all the Andean countries, except for Argentina, where this program does not exist. Participants receive remuneration (except in Bolivia, where students perform the service). The allocation systems used for these programs are heterogeneous, and in some Andean countries, the allocation is merit-based. Participation in social programs influences later professional opportunities (Ecuador, Colombia, and Venezuela) and the ability to specialize (Chile and Peru). CONCLUSIONS: It is necessary to study the impact of these programs on the professional development of the participants to design and implement quality improvement strategies tailored to each context.

Mandatory Vaccination in Europe.

BACKGROUND: Mandatory vaccination has been effective in maintaining high vaccination coverage in countries such as the United States. However, there are no peer-reviewed analyses of the association between mandates and both coverage and subsequent incidence of vaccine-preventable disease in Europe. METHODS: Using data from the European Centre for Disease Prevention and Control and the World Health Organization, we evaluated the relationship between country-level mandatory vaccination policies and (1) measles and pertussis vaccine coverage and (2) the annual incidence of these diseases in 29 European countries. Multivariate negative binomial and linear regression models were used to quantify these associations. RESULTS: Mandatory vaccination was associated with a 3.71 (95% confidence interval [CI]: 1.68 to 5.74) percentage point higher prevalence of measles vaccination and a 2.14 (95% CI: 0.13 to 4.15) percentage point higher prevalence of pertussis vaccination when compared with countries that did not have mandatory vaccination. Mandatory vaccination was only associated with decreased measles incidence for countries without nonmedical exemptions (adjusted incidence rate ratio = 0.14; 95% CI: 0.05 to 0.36). We did not find a significant association between mandatory vaccination and pertussis incidence. CONCLUSIONS: Mandatory vaccination and the magnitude of fines were associated with higher vaccination coverage. Moreover, mandatory vaccination was associated with lower measles incidence for countries with mandatory vaccination without nonmedical exemptions. These findings can inform legislative policies aimed at increasing vaccination coverage.

Insurance Coverage Criteria for Bariatric Surgery: A Survey of Policies.

BACKGROUND: Bariatric surgery remains underutilized at a national scale, and insurance company reimbursement is an important determinant of access to these procedures. We examined the current state of coverage criteria for bariatric surgery set by private insurance companies. METHODS: We surveyed medical policies of the 64 highest market share health insurance providers in the USA. ASMBS guidelines and the CMS criteria for pre-bariatric evaluation were used to collect private insurer coverage criteria, which included procedures covered, age, BMI, co-morbidities, medical weight management program (MWM), psychosocial evaluation, and a center of excellence designation. We derive a comprehensive checklist for pre-bariatric patient evaluation. RESULTS: Sixty-one companies (95%) had defined pre-authorization policies. All policies covered the RYGB, and 57 (93%) covered the LAGB or the SG. Procedures had coverage limited to center of excellence in 43% of policies (n = 26). A total of 92% required a BMI of 40 or above or of 35 or above with a co-morbidity; however, 43% (n = 23) of policies covering adolescents (n = 36) had a higher BMI requirement of 40 or above with a co-morbidity. Additional evaluation was required in the majority of policies (MWM 87%, psychosocial evaluation 75%). Revision procedures were covered in 79% (n = 48) of policies. Reimbursement of a second bariatric procedure for failure of weight loss was less frequently found (n = 41, 67%). CONCLUSIONS: A majority of private insurers still require a supervised medical weight management program prior to approval, and most will not cover adolescent bariatric surgery unless certain criteria, which are not supported by current evidence, are met.

Mandatory vaccination for infants and children: the Italian experience.

Maintaining high vaccination coverage is important in order to protect the individual and the community. Mandatory vaccination is an option in case of declining coverage. Widely used in the USA, it is considered a rather controversial issue in Europe. In Italy, after a decrease of vaccination coverage for the hexavalent and the MPR vaccine under the optimal threshold, a new law, which extended the number of mandatory vaccines from 4 to 10 and reinforced coercive measures, was introduced in July 2017. After 2 years, vaccination coverage increased for all mandatory vaccines and for the other two recommended vaccines (anti-pneumococcal and anti-meningococcal C). Although it is not possible to disentangle the role of other factors contributing to the positive outcome, consistently with the results of studies conducted in the USA, vaccine mandates appeared to be successful in increasing vaccination coverage in Italy. The long-term sustainability of the effect of mandatory vaccination and the potential negative drawbacks of the coercive measures need to be evaluated to generate scientific evidence in public health.

State Mandate Laws for Autism Coverage and High-Deductible Health Plans.

OBJECTIVES: Most states have passed insurance mandates requiring health plans to cover services for children with autism spectrum disorder (ASD). Research reveals that these mandates increased treated prevalence, service use, and spending on ASD-related care. As employer-sponsored insurance shifts toward high-deductible health plans (HDHPs), it is important to understand how mandates affect children with ASD in HDHPs relative to traditional, low-deductible plans. METHODS: Insurance claims for 2008-2012 for children covered by 3 large US insurers (United Healthcare, Aetna, and Humana) available through the Health Care Cost Institute were used to compare the effects of mandates on ASD-related spending for children in HDHPs and traditional health plans. RESULTS: Relative to children in traditional plans, mandates were associated with higher average monthly spending increases for children in HDHPs. Mandate-attributable spending differences between children enrolled in HDHPs relative to traditional plans were $77 for ASD-specific services (95% confidence interval [CI]: $10 to $144), $125 for outpatient health services (95% CI: $26 to $223), and $144 for all health services (95% CI: $36 to $253). These spending differentials were driven by differences in plan spending and not out-of-pocket (OOP) spending. CONCLUSIONS: Spending on ASD-related services attributable to autism mandates was higher among children in HDHPs, but higher spending did not translate into a greater OOP burden. For families with consistently high health care expenditures on ASD-related services, high-deductible products may be worth considering in the context of mandate laws. Families in mandate states with children with ASD enrolled in HDHPs were able to increase service use without paying more OOP.

Autism spectrum disorder, politics, and the generosity of insurance mandates in the United States.

The study of Autism Spectrum Disorder (ASD) in the United States has identified a growing prevalence of the disorder across the country, a high economic burden for necessary treatment, and important gaps in insurance for individuals with autism. Confronting these facts, states have moved quickly in recent years to introduce mandates that insurers provide coverage for autism care. This study analyzes these autism insurance mandates and demonstrates that while states have moved swiftly to introduce them, the generosity of the benefits they mandate insurers provide varies dramatically across states. Furthermore, our research finds that controlling for policy need, interest group activity, economic circumstances, the insurance environment, and other factors, the passage of these mandates and differences in their generosity are driven by the ideology of state residents and politicians-with more generous benefits in states with more liberal citizens and increased Democratic control of state government. We conclude by discussing the implications of these findings for the study of health policy, politics, and autism in America.

Real-World Cost Effectiveness of Mandatory Folic Acid Fortification of Bread-Making Flour in Australia.

BACKGROUND: In 2009, mandatory folic acid fortification of bread-making flour was introduced in Australia to reduce the birth prevalence of preventable neural tube defects (NTDs) such as spina bifida. Before the introduction of the policy, modelling predicted a reduction of 14-49 NTDs each year. OBJECTIVE: Using real-world data, this study provides the first ex-post evaluation of the cost effectiveness of mandatory folic acid fortification of bread-making flour in Australia. METHODS: We developed a decision tree model to compare different fortification strategies and used registry data to quantify the change in NTD rates due to the policy. We adopted a societal perspective that included costs to industry and government as well as healthcare and broader societal costs. RESULTS: We found 32 fewer NTDs per year in the post-mandatory folic acid fortification period. Mandatory folic acid fortification improved health outcomes and was highly cost effective because of the low intervention cost. The policy demonstrated improved equity in outcomes, particularly in birth prevalence of NTDs in births from teenage and indigenous mothers. CONCLUSIONS: This study calculated the value of mandatory folic acid fortification using real-world registry data and demonstrated that the attained benefit was comparable to the modelled expected benefits. Mandatory folic acid fortification (in addition to policies including advice on supplementation and education) improved equity in certain populations and was effective and highly cost effective for the Australian population.

Vaccination: Is There a Place for Penalties for Non-compliance?

The introduction of punitive measures to control outbreaks of measles in Europe has sparked debate and public protest about the ethical justification of penalties and exclusionary processes for non-immunisation. This article advances an ethics framework related to compulsory vaccination policies, which we use to analyse three case studies: of mandatory policies that are enforced by fines; of policies that require vaccination for the provision of social goods; and of community-led policies in which communities themselves decide how to enforce vaccination compliance. We report on contemporary, ongoing and past measures that have been used to increase vaccine uptake, consider their rationale and the related public responses, elaborate on socio-cultural and contextual influences, and discuss the ethical justification for mandatory vaccination. We argue for a measured approach that protects fundamental human rights to evidence-based information and medical counsel to support health decision making and that simultaneously raises awareness about the role of immunisation in protecting the wider community. We think more emphasis needs to be placed on immunisation as a means of promoting social good, reducing harm and protecting vulnerable groups.

Insurance Mandates and Out-of-Pocket Spending for Children With Autism Spectrum Disorder.

BACKGROUND: The health care costs associated with treating autism spectrum disorder (ASD) in children can be substantial. State-level mandates that require insurers to cover ASD-specific services may lessen the financial burden families face by shifting health care spending to insurers. METHODS: We estimated the effects of ASD mandates on out-of-pocket spending, insurer spending, and the share of total spending paid out of pocket for ASD-specific services. We used administrative claims data from 2008 to 2012 from 3 commercial insurers, and took a difference-in-differences approach in which children who were subject to mandates were compared with children who were not. Because mandates have heterogeneous effects based on the extent of children's service use, we performed subsample analyses by calculating quintiles based on average monthly total spending on ASD-specific services. The sample included 106 977 children with ASD across 50 states. RESULTS: Mandates increased out-of-pocket spending but decreased the share of spending paid out of pocket for ASD-specific services on average. The effects were driven largely by children in the highest-spending quintile, who experienced an average increase of $35 per month in out-of-pocket spending (P < .001) and a 4 percentage point decline in the share of spending paid out of pocket (P < .001). CONCLUSIONS: ASD mandates shifted health care spending for ASD-specific services from families to insurers. However, families in the highest-spending quintile still spent an average of >$200 per month out of pocket on these services. To help ease their financial burden, policies in which children with higher service use are targeted may be warranted.

Comparison Of Hospitals Participating In Medicare's Voluntary And Mandatory Orthopedic Bundle Programs.

We analyzed data from Medicare and the American Hospital Association Annual Survey to compare characteristics and baseline performance among hospitals in Medicare's voluntary (Bundled Payments for Care Improvement initiative, or BPCI) and mandatory (Comprehensive Care for Joint Replacement Model, or CJR) joint replacement bundled payment programs. BPCI hospitals had higher mean patient volume and were larger and more teaching intensive than were CJR hospitals, but the two groups had similar risk exposure and baseline episode quality and cost. BPCI hospitals also had higher cost attributable to institutional postacute care, largely driven by inpatient rehabilitation facility cost. These findings suggest that while both voluntary and mandatory approaches can play a role in engaging hospitals in bundled payment, mandatory programs can produce more robust, generalizable evidence. Either mandatory or additional targeted voluntary programs may be required to engage more hospitals in bundled payment programs.

Intracytoplasmic sperm injection use in states with and without insurance coverage mandates for infertility treatment, United States, 2000-2015.

OBJECTIVE: To compare indications and trends in intracytoplasmic sperm injection (ICSI) use for in vitro fertilization (IVF) cycles among residents of states with and without insurance mandates for IVF coverage. DESIGN: Cross-sectional analysis of the National Assisted Reproductive Technology Surveillance System from 2011 to 2015 for the main outcome and from 2000 to 2015 for trends. SETTING: IVF cycles performed in U.S. fertility clinics. PATIENT(S): Fresh IVF cycles. INTERVENTION(S): Residency in a state with an insurance mandate for IVF (n = 8 states) versus no mandate (n = 43 states, including DC). MAIN OUTCOME MEASURE(S): ICSI use by insurance coverage mandate status stratified by male-factor infertility diagnosis. RESULT(S): During 2000-2015, there were 1,356,377 fresh IVF cycles, of which 25.8% (n = 350,344) were performed for residents of states with an insurance coverage mandate for IVF. ICSI use increased significantly during 2000-2015 in states both with and without a mandate; however, for non-male-factor infertility cycles, the percentage increase in ICSI use was greater among nonmandate states (34.6% in 2000 to 73.9% in 2015) versus mandate states (39.5% in 2000 to 63.5% in 2015). For male-factor infertility cycles, this percentage increase was ∼7.3% regardless of residency in a state with an insurance mandate for IVF. From 2011 to 2015, ICSI use was lower in mandate versus nonmandate states, both for cycles with (91.5% vs. 94.5%), and without (60.3% vs. 70.9%) male-factor infertility. CONCLUSION(S): Mandates for IVF coverage were associated with lower ICSI use for non-male-factor infertility cycles.

The five-year costs and benefits of extended psychological and psychiatric assessment versus standard intake interview for women with comorbid substance use disorders treated in compulsory care in Sweden.

BACKGROUND: Women with comorbid substance use disorders are an extremely vulnerable group having an increased relative risk of negative outcomes such as incarceration, morbidity and mortality. In Sweden, women with comorbid substance use disorders may be placed in compulsory care for substance abuse treatment. Clinical intake assessment procedures are a distinct aspect of clinical practice and are a foundation upon which client motivation and continued treatment occurs. METHOD: The current study is a naturalistic quasi-experiment and aims to assess the five-year costs and benefits of a standard intake interview versus an extended psychological and psychiatric assessment for a group of chronic substance abusing women placed in compulsory care in Sweden between 1997 and 2000. Official register data on criminal activity, healthcare use, compulsory care stays and other services was retrieved and all resources used by study participants from date of index care episode was valued. In addition, the cost of providing the intake assessment was estimated. RESULTS: Results show that the extended assessment resulted in higher net costs over five years of between 256,000 and 557,000 SEK per person for women placed in care via the Law on Compulsory Care for Substance Abusers (LVM). Higher assessment costs made up a portion of this cost. The majority of this cost (47-57%) falls on the local municipality (social welfare) and 11.6-13.7% falls on the individual patient. CONCLUSIONS: Solid evidence supporting the clinical utility or incremental validity of assessment for improving treatment outcomes in this setting was not confirmed.

Impact of mandatory microchipping on traceability of sheltered dogs in the Czech Republic.

Records of 4,455 sheltered dogs were analyzed to compare the numbers of traceable (able to be reunited with original caregivers) and untraceable (unable to be reunited with original caregivers) dogs before (Period 1) and after (Period 2) introduction of a mandatory microchipping. Records were also used to compare the numbers of microchipped dogs, to compare dogs' reunification with caregivers, and to estimate possible financial savings. In Period 1, 51.8% of the dogs were untraceable (median length of stay = 14 days) and 48.2% were traceable (median length of stay = 1 day). Of all traceable dogs, 24.5% were microchipped, and 67.5% of microchipped dogs were traceable. In Period 2, 57.1% of dogs were traceable (median length of stay = 0 days), and 42.9% were untraceable (median length of stay = 12 days). Of all traceable dogs, 61.4% had a microchip, and 80% of microchipped dogs were traceable. In Period 2, authorities saved more than US$43,400 on unreclaimed dog care. Mandatory microchipping of dogs appears to be an effective measure to increase reunification of sheltered dogs, decrease length of stay, and save authority funds.

Association Between Medicare's Mandatory Hospital Value-Based Purchasing Program and Cost Inefficiency.

BACKGROUND: The Patient Protection and Affordable Care Act instituted pay-for-performance programs, including Hospital Value-Based Purchasing (HVBP), designed to encourage hospital quality and efficiency. OBJECTIVE AND METHOD: While these programs have been evaluated with respect to their implications for care quality and financial viability, this is the first study to assess the relationship between hospitals' cost inefficiency and their participation in the programs. We estimate a translog specification of a stochastic cost frontier with controls for participation in the HVBP program and clinical and outcome quality for California hospitals for 2012-2015. RESULTS: The program-participation indicators' parameters imply that participants were more cost inefficient than their peers. Further, the estimated coefficients for summary process of care quality indexes for three health conditions (acute myocardial infarction, pneumonia, and heart failure) suggest that higher quality scores are associated with increased operating costs. CONCLUSION: The estimated coefficients for the outcome quality variables suggest that future determination of HVBP payment adjustments, which will depend solely on mortality rates as measures of clinical care quality, may not only be aligned with increasing healthcare quality but also reducing healthcare costs.