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Objective: To examine the relationship between the level of state funding for Home‐ and Community‐Based Services (HCBS) and state overall and dimension‐specific performances in Long‐Term Services and Supports (LTSS). Data Sources and Study Setting: We employed state‐level secondary data from the Medicaid LTSS Annual Expenditures Reports, the American Association of Retired Persons (AARP) State Scorecards, the U.S. Census, and Federal Reserve Economic data, spanning the timeframe of 2010–2020. Study Design: Overall state LTSS rankings, along with dimension‐specific rankings, were modeled separately against state Medicaid spending on HCBS relative to total Medicaid spending on LTSS. All models were adjusted for state covariates, secular trend, and state fixed effects. Data Collection/Extraction Methods: The study sample included all 50 states and the District of Columbia. However, California, Delaware, Illinois, and Virginia were excluded from FY2019 due to missing data on Medicaid HCBS expenditures. Principal Findings: Every 10 percentage‐point increase in the proportion of Medicaid LTSS spending to HCBS demonstrated 2.05 points improvement (95% confidence interval [CI]: −3.88 to 0.22, p = 0.03) in rankings for state overall LTSS system performance, 2.92 points improvement (95% CI: −4.87 to 0.98, p < 0.01) in rankings for the Choice of Setting and Provider dimension, as well as 1.73 points (95% CI: −3.14 to 0.32, p = 0.02) ranking improvement in the dimension of Effective Transitions. Conclusions: Our study suggested promising effects of increased state funding for HCBS on LTSS performance. [ABSTRACT FROM AUTHOR]

Objective: To compare hospital-community partnerships among safety-net hospitals relative to non-safety-net hospitals, and explore whether hospital-community partnerships are associated with reductions in readmission rates.Data Sources: Data from four nationwide hospital-level datasets for 2015-2016, including American Hospital Association (AHA) annual survey, Hospital Inpatient Prospective Payment System (IPPS) data, CMS Hospital Compare, and County Health Rankings National (CHRN) data.Study Design: We first examined how safety-net hospitals partner with nine different community providers, and how the overall and individual partnership patterns differ from those in non-safety-net hospitals. We then explored their association with 30-day readmission rates by diagnosis and hospital wide.Data Collection/extraction Methods: We included 1979 hospitals across 50 US states.Principal Findings: Safety-net hospitals were more engaged in hospital-community partnerships, especially with local public health, local governments, social services, nonprofits, and insurance companies, relative to their non-safety-net peers. However, we found that such partnerships were not significantly related to reductions in readmission rates. The findings indicated that merely partnering with various community organizations may not be associated with readmission rate reduction.Conclusions: Before promoting partnerships with various community organizations for its own sake, further prospective, longitudinal, and evidence-based guidance derived from the study of hospital-community partnerships is needed to make meaningful recommendations aimed at readmission rate reduction in safety-net hospitals. [ABSTRACT FROM AUTHOR]

Objective: To measure the burden of financing health care costs and quantify redistribution among population groups.Data Sources: A synthetic population using data combined from multiple sources, including the Survey of Income and Program Participation (SIPP), Medical Expenditure Panel Survey (MEPS), Kaiser Family Foundation (KFF)/Health Research Educational Trust (HRET) Employer Health Benefits Survey, American Community Survey (ACS), and National Health Expenditure Accounts (NHEA).Study Design: We estimate two dollar amounts for each individual in the synthetic population: (a) payments to finance health care services, which includes all payments by a household and their employers to finance health care, including premiums, out-of-pocket payments, federal and state taxes, and other payments; and (b) the dollar value of health care services received, which equals the amount paid to providers for those services.Data Extraction Methods: We linked the nationally representative survey data using statistical matching. We allocated health care expenditures from the NHEA to individuals and households based on expenditures reported in the MEPS.Principal Findings: We show that higher-income households pay the most to finance health care in dollar amounts, but the burden of payments as a share of income is greater among lower-income households.Conclusions: Accounting for all sources of payments provides a clear picture of the burden of financing health care costs, and how that burden is spread under our current financing system. [ABSTRACT FROM AUTHOR]

Objective: To estimate the effect of out-of-pocket (OOP) cost on nonadherence to classes of cardiometabolic medications among patients with diabetes.Data Sources/setting: Electronic health records from a large, health care delivery system for 223,730 patients with diabetes prescribed 842,899 new cardiometabolic medications during 2006-2012.Study Design: Observational, new prescription cohort study of the effect of OOP cost on medication initiation and adherence.Data Collection: Adherence and OOP costs were based on pharmacy dispensing records and benefits.Principal Findings: Primary nonadherence (never dispensed) increased monotonically with OOP cost after adjusting for demographics, neighborhood socioeconomic status, Medicare, medical financial assistance, OOP maximum, deductibles, mail order pharmacy incentive and use, drug type, generic or brand, day's supply, and comorbidity index; 7 percent were never dispensed the new medication when OOP cost ≥$11, 5 percent with OOP cost of $1-$10, and 3 percent when the medication was free of charge (p < .0001). Higher OOP cost was also strongly associated with inadequate secondary adherence (≥20 percent of time without adequate medication). There was no clinically significant or consistent relationship between OOP costs and early nonpersistence (dispensed once, never refilled) or later stage nonpersistence (discontinued within 24 months).Conclusions: Cost-sharing may deter clinically vulnerable patients from initiating essential medications, undermining adherence and risk factor control. [ABSTRACT FROM AUTHOR]

Objective: To isolate the effect of greater inpatient cost-sharing on Medicaid entry among Medicare beneficiaries.Data Sources: Medicare administrative data (years 2007-2010) were linked to nursing home assessments and area-level socioeconomic indicators.Study Design: Medicare beneficiaries who are readmitted to a hospital must pay an additional deductible ($1,100 in 2010) if their readmission occurs more than 59 days following discharge. In a regression discontinuity analysis, we take advantage of this Medicare benefit feature to test whether beneficiaries with greater cost-sharing have higher rates of Medicaid enrollment.Data Extraction Methods: We identified 221,248 Medicare beneficiaries with an initial hospital stay and a readmission 53-59 days later (no deductible) or 60-66 days later (charged a deductible).Principal Findings: Among beneficiaries in low-socioeconomic areas with two hospitalizations, those readmitted 60-66 days after discharge were 21 percent more likely to join Medicaid compared with those readmitted 53-59 days following their initial hospitalization (absolute difference in adjusted risk of Medicaid entry: 3.7 percent vs. 3.1 percent, p = .01).Conclusions: Increasing Medicare cost-sharing requirements may promote Medicaid enrollment among low-income beneficiaries. Potential savings from an increased cost-sharing in the Medicare program may be offset by increased Medicaid participation. [ABSTRACT FROM AUTHOR]

Objective: To forecast out-of-pocket health care spending among older adults. Long-term forecasts allow policy makers to explore potential impacts of policy scenarios, but existing microsimulations do not incorporate details of supplemental insurance coverage and income effects on health care spending.Data Sources: Dynamic microsimulation calibrated to survey and administrative data.Study Design: We augment Urban Institute's Dynamic Simulation of Income Model (DYNASIM) with modules that incorporate demand responses and economic equilibria, with dynamics driven by exogenous technological change. A lengthy technical appendix provides details of the microsimulation model and economic assumptions for readers interested in applying these techniques.Principal Findings: The model projects total out-of-pocket spending (point of care plus premiums) as a share of income for adults aged 65 and older. People with lower incomes and poor health fare worse, despite protections of Medicaid. Spending rises 40 percent from 2012 to 2035 (from 10 to 14 percent of income) for the median beneficiary, but it increases from 5 to 25 percent of income for low-income beneficiaries and from 23 to 29 percent for the near poor who are in fair/poor health.Conclusions: Despite Medicare coverage, near-poor seniors will face out-of-pocket spending that would render them, in practical terms, underinsured. [ABSTRACT FROM AUTHOR]

Objective: To provide guidance on selecting the most appropriate price index for adjusting health expenditures or costs for inflation.Data Sources: Major price index series produced by federal statistical agencies.Study Design: We compare the key characteristics of each index and develop suggestions on specific indexes to use in many common situations and general guidance in others.Data Collection/extraction Methods: Price series and methodological documentation were downloaded from federal websites and supplemented with literature scans.Principal Findings: The gross domestic product implicit price deflator or the overall Personal Consumption Expenditures (PCE) index is preferable to the Consumer Price Index (CPI-U) to adjust for general inflation, in most cases. The Personal Health Care (PHC) index or the PCE health-by-function index is generally preferred to adjust total medical expenditures for inflation. The CPI medical care index is preferred for the adjustment of consumer out-of-pocket expenditures for inflation. A new, experimental disease-specific Medical Care Expenditure Index is now available to adjust payments for disease treatment episodes.Conclusions: There is no single gold standard for adjusting health expenditures for inflation. Our discussion of best practices can help researchers select the index best suited to their study. [ABSTRACT FROM AUTHOR]

Objective: To estimate health care expenditure trends among young adults ages 19-25 before and after the 2010 implementation of the Affordable Care Act (ACA) provision that extended eligibility for dependent private health insurance coverage.Data Sources: Nationally representative Medical Expenditure Panel Survey data from 2008 to 2012.Study Design: We conducted repeated cross-sectional analyses and employed a difference-in-differences quantile regression model to estimate health care expenditure trends among young adults ages 19-25 (the treatment group) and ages 27-29 (the control group).Principal Findings: Our results show that the treatment group had 14 percent lower overall health care expenditures and 21 percent lower out-of-pocket payments compared with the control group in 2011-2012. The overall reduction in health care expenditures among young adults ages 19-25 in years 2011-2012 was more significant at the higher end of the health care expenditure distribution. Young adults ages 19-25 had significantly higher emergency department costs at the 10th percentile in 2011-2012. Differences in the trends of costs of private health insurance and doctor visits are not statistically significant.Conclusions: Increased health insurance enrollment as a consequence of the ACA provision for dependent coverage has successfully reduced spending and catastrophic expenditures, providing financial protections for young adults. [ABSTRACT FROM AUTHOR]

Objective: To investigate factors affecting willingness to pay (WTP) for health insurance of older adults in a longitudinal setting in Germany.Data Sources: Survey data from a cohort study in Saarland, Germany, from 2008-2010 and 2011-2014 (n1  = 3,124; n2  = 2,761) were used.Study Design: Panel data were taken at two points from an observational, prospective cohort study.Data Collection: WTP estimates were derived using a contingent valuation method with a payment card. Participants provided data on sociodemographics, lifestyle factors, morbidity, and health care utilization.Principal Findings: Fixed effects regression models showed higher individual health care costs to increase WTP, which in particular could be found for members of private health insurance. Changes in income and morbidity did not affect WTP among members of social health insurance, whereas these predictors affected WTP among members of private health insurance.Conclusions: The fact that individual health care costs affected WTP positively might indicate that demanding (expensive) health care services raises the awareness of the benefits of health insurance. Thus, measures to increase WTP in old age should target at improving transparency of the value of health insurances at the moment when individual health care utilization and corresponding costs are still relatively low. [ABSTRACT FROM AUTHOR]

Objective: To measure variation in payment rates under Medicare's Inpatient Prospective Payment System (IPPS) and identify the main payment adjustments that drive variation.Data Sources/study Setting: Medicare cost reports for all Medicare-certified hospitals, 1987-2013, and Dartmouth Atlas geographic files.Study Design: We measure the Medicare payment rate as a hospital's total acute inpatient Medicare Part A payment, divided by the standard IPPS payment for its geographic area. We assess variation using several measures, both within local markets and nationally. We perform a factor decomposition to identify the share of variation attributable to specific adjustments. We also describe the characteristics of hospitals receiving different payment rates and evaluate changes in the magnitude of the main adjustments over time.Data Collection/extraction Methods: Data downloaded from the Centers for Medicare and Medicaid Services, the National Bureau of Economic Research, and the Dartmouth Atlas.Principal Findings: In 2013, Medicare paid for acute inpatient discharges at a rate 31 percent above the IPPS base. For the top 10 percent of discharges, the mean rate was double the IPPS base. Variations were driven by adjustments for medical education and care to low-income populations. The magnitude of variation has increased over time.Conclusions: Adjustments are a large and growing share of Medicare hospital payments, and they create significant variation in payment rates. [ABSTRACT FROM AUTHOR]

Objective: The design of health insurance, and the role out-of-pocket (OOP) payments play in it, is a key policy issue as rising health costs have encouraged greater cost-sharing measures. This paper compares the percentage of Americans spending large amounts OOP to meet their health needs with percentages in eight other developed countries. By disaggregating by age and income, the paper focuses on the poor and elderly populations within each.Data Source: The study uses nationally representative household survey data made available through the Luxembourg Income Study. It includes nations with high, medium, and low levels of OOP spending.Study Design: Households have high medical spending when their OOP expenditures exceed a threshold share of income. I calculate the share of each nation's population, as well as subpopulations within it, with high OOP expenditures.Principal Findings: The United States is not alone in exposing large numbers of citizens to high OOP expenses. In six of the other eight countries, one-quarter or more of low-income citizens devoted at least 5 percent of their income to OOP expenses, and in all but two countries, more than 1 in 10 elderly citizens had high medical expenses.Conclusions: For some populations in the sample nations, health insurance does not provide adequate financial protection and likely contributes to inequities in health care delivery and outcomes. [ABSTRACT FROM AUTHOR]

Objective: Examine differences in health care expenditures between foreign-born and U.S.-born adults in late mid-life, and how these differences change after age 65, when Medicare is near-universal.Data: Medical Expenditures Panel Survey data (2000-2010) on adults ages 55-75 years (n = 46,132) to examine annual total and payer-specific expenditures.Study Design: We use (1) propensity score matching to generate quasi-experimental samples with equivalent health needs and health care preferences, (2) generalized linear modeling to estimate group differences in expenditures, and (3) bootstrapping methods to obtain variance estimates for significance testing.Principal Findings: Among adults ages 55-64, the foreign-born spend $3,314 (p < .001) less on health care, even when they have equivalent health needs and health care preferences. This difference is due mainly to lower spending through private insurance. After age 65, differences in total spending disappear but not differences in payer-specific spending. The foreign-born continue to spend significantly less through private insurance and begin to spend significantly more through Medicare and Medicaid.Conclusion: Foreign-born adults in late mid-life spend significantly less on health care than U.S.-born adults. After age 65, with near-universal Medicare coverage, differences in total spending disappear between the groups, although differences in spending by payer persist. [ABSTRACT FROM AUTHOR]

Objective: To estimate the relative importance of organizational-, procedural-, and interpersonal-level features of health care delivery systems from the patient perspective.Data Sources/study Setting: We designed four discrete choice experiments (DCEs) to measure patient preferences for 21 health system attributes. Participants were recruited through the online patient portal of a large health system. We analyzed the DCE data using random effects logit models.Data Collection/extraction Methods: DCEs were performed in which respondents were provided with descriptions of alternative scenarios and asked to indicate which scenario they prefer. Respondents were randomly assigned to one of the three possible health scenarios (current health, new lung cancer diagnosis, or diabetes) and asked to complete 15 choice tasks. Each choice task included an annual out-of-pocket cost attribute.Principal Findings: A total of 3,900 respondents completed the survey. The out-of-pocket cost attribute was considered the most important across the four different DCEs. Following the cost attribute, trust and respect, multidisciplinary care, and shared decision making were judged as most important. The relative importance of out-of-pocket cost was consistently lower in the hypothetical context of a new lung cancer diagnosis compared with diabetes or the patient's current health.Conclusions: This study demonstrates the complexity of patient decision making processes regarding features of health care delivery systems. Our findings suggest the importance of these features may change as a function of an individual's medical conditions. [ABSTRACT FROM AUTHOR]

Objective: Millions of low-income Americans will gain health insurance through Medicaid under the Affordable Care Act. This study assesses the impact of previous Medicaid expansions on mental health services utilization and out-of-pocket spending.Data Sources: Secondary data from the 1998-2011 Medical Expenditure Panel Survey Household Component merged with National Health Interview Survey and state Medicaid eligibility rules data.Study Design: Instrumental variables regression models were used to estimate the impact of expanded Medicaid eligibility on health insurance coverage, mental health services utilization, and out-of-pocket spending for mental health services.Data Extraction Methods: Person-year files were constructed including adults ages 21-64 under 300 percent of the Federal Poverty Level.Principal Findings: Medicaid expansions significantly increased health insurance coverage and reduced out-of-pocket spending on mental health services for low-income adults. Effects of expanded Medicaid eligibility on out-of-pocket spending were strongest for adults with psychological distress. Expanding Medicaid eligibility did not significantly increase the use of mental health services.Conclusions: Previous Medicaid eligibility expansions did not substantially increase mental health service utilization, but they did reduce out-of-pocket mental health care spending. [ABSTRACT FROM AUTHOR]

Objectives: Previous patient-level acute myocardial infarction (AMI) research has found higher hospital spending to be associated with improved survival; however, survivor-treatment selection bias traditionally has been overlooked. The purpose of this study was to examine the AMI cost-outcome relationship, taking into account this form of bias.Data Sources: Hospital Discharge Abstract data tracked costs for AMI hospitalizations. Ontario Vital Statistics data tracked patient mortality.Study Design: A standard Cox survival model was compared to an extended Cox model using hospital costs as a time-varying covariate to examine the impact of cost on 1-year survival in a cohort of 30,939 first-time AMI patients in Ontario, Canada, from 2007 to 2010.Principal Findings: Higher patient-level AMI spending decreased the hazard of dying (Standard Model: log-cost hazard ratio: 0.513, 95 percent CI: 0.479-0.549; Extended Model: log-cost hazard ratio: 0.700, 95 percent CI: 0.645-0.758); however, the protective effect was overestimated by 62 percent when survivor-treatment bias was overlooked. In the extended model, a 10 percent increase in spending was associated with a 3.6 percent decrease in hazard of death.Conclusion: The findings of this study suggest that if survivor-treatment bias is overlooked, future research may materially overstate the protective effect of patient-level spending on outcomes. [ABSTRACT FROM AUTHOR]

Background: Fiscal constraints faced by Medicare are leading to policies designed to reduce expenditures. Evidence of the effect of reduced reimbursement on the mortality of Medicare patients discharged from all major hospital service lines is limited.Methods: We modeled risk-adjusted 30-day mortality of patients discharged from 21 hospital service lines as a function of service line profitability, service line time trends, and hospital service line and year-fixed effects. We simulated the effect of alternative revenue-neutral reimbursement policies on mortality. Our sample included all Medicare discharges from PPS-eligible hospitals (1997, 2001, and 2005).Results: The results reveal a statistically significant inverse relationship between changes in profitability and mortality. A $0.19 average reduction in profit per $1.00 of costs led to a 0.010-0.020 percentage-point increase in mortality rates (p < .001). Mortality in newly unprofitable service lines is significantly more sensitive to reduced payment generosity than in service lines that remain profitable. Policy simulations that target service line inequities in payment generosity result in lower mortality rates, roughly 700-13,000 fewer deaths nationally.Conclusions: The policy simulations raise questions about the trade-offs implicit in universal reductions in reimbursement. The effect of reduced payment generosity on mortality could be mitigated by targeting highly profitable services only for lower reimbursement. [ABSTRACT FROM AUTHOR]