Decades of research shows that small firms are much less likely to offer health insurance than large firms, but less is known about differences among small employers. We examine this issue using the Medical Expenditure Panel Survey-Insurance Component with Administrative Records (MEPS-ICAR), a unique employer-employee linked data set that is constructed by matching the Medical Expenditure Panel Survey-Insurance Component (MEPS-IC) to Internal Revenue Service administrative records and the Decennial Census. Multivariate analyses show that among firms with fewer than 50 workers, the probability that workers receive an insurance offer is positively associated with higher median workforce incomes, and conditional offers of dependent coverage increase when the majority of workers are married or from a family with at least three members. This first application of the MEPS-ICAR highlights the significance of workforce characteristics in shaping small employer insurance benefits and the data's usefulness for expanding analyses of policy changes, wage-benefit tradeoffs, and health insurance benefits.

This study describes trends in the number of administrators in Pennsylvania hospitals from 1991 to 2020, and in the proportion of administrators to other hospital staff. Data are from the Pennsylvania Department of Health and the American Hospital Association. We find that between 1991 and 2020, the average number of administrators increased by 102% (60% when adjusted for patient volume). RNs, all nurses, and total hospital staff did not increase to the same extent, so the proportion of administrators to these staff increased by 24%, 33%, and 70% respectively. Common policies for reducing administrative costs may or may not apply to reducing administrator growth. Other policies should be explored as we discover specifics about this growth. Future studies should include data from other states and lower-level administrative staff. Studies should also examine the relationship between the number and proportion of administrators and nurse staffing, costs and quality of care.

Enrollment in Medicare Advantage (MA) Dual-Eligible Special Needs Plans (D-SNPs) among individuals dually eligible for Medicare and Medicaid has more than tripled over the past decade. Little is known about whether D-SNP plan design differs from standard MA plan design nor whether this design reflects the needs of dual-eligible enrollees. We characterize the degree to which D-SNPs specialize in an important plan design dimension-provider networks. We find that in 2022, 46% of D-SNPs offer networks that are distinct from the insurer's standard MA plan networks. Compared with D-SNP networks that are shared with standard MA plans, specialized D-SNP networks include more psychiatrists, Ob/Gyn's, and neurologists, providers that specialize in treating conditions more common among dually eligible enrollees. Network specialization is more common among insurers participating in the local Medicaid market and less common in provider shortage areas, suggesting investment in Medicaid and reduced provider negotiation costs may facilitate specialization.

Little is known about how take-up of Medicaid among eligible adults has changed since 2014. This study used data from the Medical Expenditure Panel Survey to examine changes in Medicaid enrollment among Medicaid-eligible adults between 2014 and 2019. Eligibility for Medicaid was simulated using state- and year-specific eligibility rules. Among all Medicaid-eligible citizen adults aged 19-64 years, the proportion enrolled in Medicaid increased from 55.5% in 2014-2015 to 61.9% in 2016-2017, and then remained approximately at the same level in 2018-2019 (61.5%). Among adults who became eligible because of the Medicaid expansions, the proportion enrolled in Medicaid increased from 44.1% in 2014-2015 to 53.8% in 2016-2017. Among pre-Affordable Care Act (ACA)-eligible adults, there was no statistically significant change in the proportion enrolled in Medicaid between 2014-2015 and 2016-2017 (66.8% and 69.7%, respectively). There were significant differences in changes in take-up rates across population subgroups.

Health care organizations are increasingly using team huddles to enhance communication, improve patient experience, and deliver timely care. However, established practices, resource constraints, and hierarchical role dynamics can hinder the effectiveness of huddling. This study investigates the dynamics of care huddle implementation through interviews with care providers and managers of an observation unit in a U.S. hospital. Qualitative analysis of interview data reveals that huddle adoption enhances relational coordination (RC), thus highlighting the importance of both coaching interventions in fostering proactive behavior and the building of a work environment aligned toward shared goals. The findings affirm RC as a dynamic change model, examining its interplay with organizational processes and structure. The study underscores the significance of adaptations in work processes, the role of informal boundary spanners in facilitating cross-departmental coordination, and structural changes that increase autonomy for low-power actors. We offer actionable recommendations for health care organizations aiming to improve care coordination.

Prospective payments for health care providers require adequate risk adjustment (RA) to address systematic variation in patients' health care needs. However, the design of RA for provider payment involves many choices and difficult trade-offs between incentives for risk selection, incentives for cost control, and feasibility. Despite a growing literature, a comprehensive framework of these choices and trade-offs is lacking. This article aims to develop such a framework. Using literature review and expert consultation, we identify key design choices for RA in the context of provider payment and subsequently categorize these choices along two dimensions: (a) the choice of risk adjusters and (b) the choice of payment weights. For each design choice, we provide an overview of options, trade-offs, and key references. By making design choices and associated trade-offs explicit, our framework facilitates customizing RA design to provider payment systems, given the objectives and other characteristics of the context of interest.

State full practice authority (FPA) laws are designed to permit NPs to practice autonomously from physicians. Little is known regarding how FPA laws affect NPs' practice autonomy in daily practice. This study used nationwide survey data from 20,830 NPs to estimate how NPs' practice autonomy differs between NPs in FPA and non-FPA states. NPs in states with FPA laws were more than twice as likely as NPs in non-FPA states to practice in clinic settings with no onsite physicians and were twice as likely to not have a physician collaborator. Associations between FPA laws and four other indicators of practice autonomy were positive but smaller in magnitude. States with FPA laws more than 10 years experienced larger changes in nurse practitioner (NP) autonomy compared with states with FPA laws in effect less than 10 years. FPA laws may promote the development of autonomous NP practice sites, thereby expanding access in underserved populations.

While community-based palliative care (CBPC) programs have been expanding, there remain important obstacles to widespread use. Since provider perspectives on CBPC remain underexplored, we conducted a scoping review to summarize provider perspectives regarding barriers and facilitators to implementation of adult CBPC in the United States. We systematically searched OVID, MEDLINE, and CINAHL for peer-reviewed qualitative research published from January 1, 2010 to January 9, 2024, then used PRISM framework synthesis to organize themes into provider, organization, and external environment levels. Thirty-four articles were included. At the provider level, barriers included misperceptions of palliative care (PC) by referring providers and poor communication, while facilitators included multidisciplinary teams and referring provider education. At the organizational level, time constraints were barriers, while leadership buy-in and co-located clinics were facilitators. At the external environment level, limited PC workforce and inadequate reimbursement were barriers. Our findings suggest that efforts aimed at scaling CBPC must address factors at the provider, organizational, and policy levels.

The number of hospitals screening patients for health-related social needs (HRSNs) has increased substantially in recent years, yet little is known about the extent to which hospitals invest in programs or strategies aimed at addressing identified needs. Using data from the 2022 American Hospital Association (AHA) Annual Survey for 2,468 non-federal general medical and surgical hospitals, this study explored screening rates and related interventions for eight HRSNs: housing, food insecurity, utilities, interpersonal violence, transportation, employment or income, education, and social isolation. Sample hospitals screened for an average of 6.1 HRSNs and had programs or strategies for an average of 5.4 HRSNs. Hospitals that screened their patients for HRSNs were significantly more likely to invest in interventions aimed at addressing these needs. Serving patients more holistically by addressing both medical and social needs has the potential to improve health outcomes and ultimately reduce health disparities.

This study assessed the distribution of Covid Provider Relief Funds (PRFs) to 3,886 private and public general acute care hospitals during 2020-2022. Marginal effects from two-part regression were analyzed. More than 13% of study hospitals did not receive PRFs. Some targeted groups of hospitals, that is, safety-net hospitals and high-impact hospitals (those with high COVID-19 admissions), were the most likely to receive PRFs. Hospitals providing the most uncompensated care, and facilities serving counties with high concentrations of Black or Hispanic populations, were less likely to receive PRFs. Among facilities receiving subsidies, rural, high-impact, safety-net, and financially vulnerable hospitals received more PRFs in relation to their total revenues. Those serving impoverished communities received a larger proportion of PRFs relative to their total revenues, while those in areas with a high concentration of Hispanics received a smaller proportionate subsidy.

Post-acute care users in Medicare Advantage (MA) plans may seek coverage changes if facing issues with plan benefits. In 2019, the Centers for Medicare and Medicaid Services extended the deadline to disenroll from an MA plan from February 14 to March 31 and, for the first time, permitted beneficiaries to switch to a different MA plan instead of traditional Medicare. Using 2016-2019 Medicare administrative data, we implemented a difference-in-differences approach to evaluate the impact of this policy on disenrollment from a plan within 1 month of initiating skilled nursing facility or home health services. When MA disenrollment rules became more flexible, overall rates of exiting MA plans did not change. Switching to a different MA plan increased after the policy change, but this outcome was so rare that this increase did not affect overall rates of exiting MA plans.

This systematic review investigates disparities in COVID-19 outcomes (infections, hospitalizations, and deaths) between urban and rural populations in the United States. Of the 3,091 articles screened, 55 were selected. Most studies ( = 43) conducted national analyses, using 2020 data, with some extending into 2021. Findings show urban areas had higher COVID-19 cases and hospitalizations in 2020, while rural areas saw increased cases in 2021 and mixed hospitalization results. Urban areas also had higher mortality rates in 2020, with rural rates rising in 2021 and 2022. Most studies did not explore reasons for urban/rural differences. The few that did found that vulnerable groups, including racially and ethnically minoritized populations, older adults, and those with comorbidities and lower socioeconomic status and vaccination rates, experienced exacerbated disparities in rural regions. COVID-19 outcomes varied over time and by area due to population density, healthcare infrastructure, and socioeconomic factors. Tailored interventions are essential for health equity and effective policies.

The supply of personal care aides (PCAs), who assist people receiving home care, is a growing concern. PCA shortages result, in part, from the low wages earned by these workers. State policies have had some effect on wages. Self-direction (SD) may be associated with wages because SD allows home care recipients to hire and manage workers, including setting wages in most states. We used wage data from the Bureau of Labor Statistics to examine the association between SD and the wages of PCAs. We found implementation of SD did not have a consistent association with PCA wages, with wages improving in some states and worsening in others. We also found little difference in PCA wages between states that allow participants to set worker wages and those that do not. SD does not seem to improve PCA wages in states, so other policy strategies will be needed.

Little is known about online medical record (OMR) use among caregivers, including changes in OMR use through the COVID-19 pandemic. This study compares OMR use among caregivers and non-caregivers before and during the COVID-19 pandemic, identifies reasons for non-use, and examines the association between caregiving status and characteristics with OMR use. Secondary data analysis of the nationally representative Health Information National Trends Survey data from 2018 to 2022 ( = 14,034). Caregivers were more likely to use the OMR post-COVID (51.8%) compared with pre-COVID (44.7%). Caregiving was significantly associated with increased likelihood of OMR use post-COVID (odds ratio = 1.67), but not pre-COVID. The increased use of OMR among caregivers during COVID-19 highlights the potential of OMRs as a support tool for caregivers' health and well-being. Interventions and policies to improve OMR engagement must address persisting disparities across demographic groups and encourage caregivers' OMR use to support their role and enhance their personal health management.

Public health care policymakers and payers are increasingly investing in efforts to address patients' health-related social needs (HRSNs) as a strategy for improving health while controlling or reducing costs. However, evidence regarding the implementation and impact of HRSN interventions remains limited. California's Whole Person Care Pilot program (WPC) was a Medicaid Section 1115 waiver demonstration program focused on the provision of care coordination and other services to address eligible beneficiaries' HRSN. In this study, we examine pilot-level variation in impact on acute care utilization and identify factors associated with differential outcomes. The majority of pilots reduced emergency department (ED) visits for enrollees relative to matched controls; however, only four pilots reduced both ED visits and hospitalizations. Coincidence analysis results highlight the importance of cross-sector partnerships, field-based outreach and engagement, and adequate program investment in differentiating pilots that reduced acute care utilization from those that did not.

The onset of the COVID-19 pandemic in March 2020 had a sudden and substantial impact on health care utilization for most, if not all, individuals. We study the impact the pandemic had on the population insured in the individual and small group markets under the Patient Protection and Affordable Care Act (ACA) of 2010, using administrative claims data from January 2019 through December 2021. Our results demonstrated how health care utilization differed between the acute phase (i.e., 2020) and the post-acute phase (i.e., 2021) compared with the pre-pandemic phase. We found that in the ACA markets, most spending and utilization categories decreased drastically during the initial months of the pandemic and recovered by the end of 2021. While the role of telehealth among office visits decreased substantially by the end of 2021, it remained the main mode of delivery for mental health services.

Addressing patient experience is a priority in the health care system. Hospital Consumer Assessment of Providers and Systems (HCAHPS) survey results incentivize hospitals to elevate patient experience, a factor in patient-centered care. Although hospital nursing resources have been positively associated with better HCAHPS ratings, it is unknown how changes in nursing resources are associated with changes in HCAHPS ratings over time. This two-period longitudinal study ranked the associations between changes in nurse staffing, skill mix, nurse education, and work environment on HCAHPS ratings and found that changes in the work environment had the strongest associations (β = 2.29;  < .001) with improved HCAHPS ratings. Our findings provide hospital administrators with empirical evidence that may help make informed decisions on how to best invest limited resources to improve HCAHPS ratings, including the potential utility of improving the work environment through enhancing Nursing Quality of Care and Nurse Participation in Hospital Affairs.

This article estimates differences and difference-in-differences in patient experiences for Veterans Health Administration (VA) compared to non-VA patients in 2017, when there was concern about the health quality of VA hospitals, and in 2021, the second year of the COVID-19 pandemic, both overall, and for specific patient groups. We used data from the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) survey. In 2017, HCAHPS performance was somewhat better for non-VA than for VA hospitals, with Care Transition being the only measure for which VA hospitals performed better on average. By 2021, HCAHPS performance was better for VA than for non-VA hospitals for all but two measures (Quietness and Discharge Information), for which there were no differences from non-VA hospitals. In 2017, the VA provided worse experiences than non-VA hospitals for Black and poor-health patients; in 2021, VA hospitals outperformed non-VA hospitals for these, and all patient subgroups examined.

This study estimates the effect of nursing home closure on occupancy, net profit margin, and operating margin of nearby nursing homes. We use national nursing home data from 2009 to 2019 from Medicare cost reports, Medicare Provider of Services (POS), and LTCfocus.org data. Using the Callaway and Sant'Anna difference-in-differences model, we compare the changes in occupancy, net profit margin, and operating margin between incumbent nursing homes in markets with any closure and nursing homes in markets without a closure, overall, and across rurality. Our findings suggest that nursing home closure improves the occupancy rates of remaining nursing homes in the same market in rural areas but there is little evidence of effects in metropolitan and micropolitan areas. Nursing home regulators and local officials should consider the long-term care market heterogeneity when considering interventions targeted at nursing home closure.

Many Veterans receive Department of Veterans Affairs (VA)-purchased care from non-VA facilities but little is known about factors that Veterans consider for this choice. Between May 2020 and August 2021, we surveyed VA-purchased care-eligible VA patients about barriers and facilitators to choosing where to receive care. We examined the association between travel time to their VA facility and their choice of VA-purchased care (VA-paid health care received in non-VA settings) versus VA facility and whether this association was modified by distrust. We received 1,662 responses and 692 (42%) chose a VA facility. Eighty percent reported quality care was in their top three factors that influenced their decision. Respondents with the highest distrust and who lived >1 hr from the nearest VA facility had the lowest predicted probability (PP) of choosing VA (PP 15%; 95% confidence interval: 10%-20%). Veterans value quality of care. VA and other health care systems should consider patient-centered ways to improve and publicize quality and reduce distrust.

We examined peer-reviewed publications analyzing data from the English GP Patient Survey (GPPS), U.S. National Health Interview Survey (NHIS), and California Health Interview Survey (CHIS) to explore how the health of sexual minority populations varies across settings and subgroups. We searched for English language articles published 2011-2022, screening abstracts ( = 112), reviewing full text ( = 97), and extracting data ( = 85). We conducted a content analysis to identify patterns across settings for sexual minority people compared with heterosexual counterparts and each other. Across all settings, sexual minority adults had poorer health care access, worse health outcomes and patient experiences, more detrimental health behaviors, and greater health care services utilization (reflecting risk awareness and need). When subgroup data were reported, differences were greater among women, except for HIV and related cancers, which were most prevalent among sexual minority men. Sexual minority people generally reported significantly worse health access, outcomes, and behaviors in all three settings.