Medical Care最新文献

{"title":"Receipt of Cancer Surgery: A Comparison of Cancer Registry Data and Medicare Claims.","authors":"Yoon Duk Hong, Lindsey Enewold, Christopher A Zeruto, Angela B Mariotto","doi":"10.1097/MLR.0000000000002364","DOIUrl":"10.1097/MLR.0000000000002364","url":null,"abstract":"<p><strong>Background: </strong>The Surveillance, Epidemiology, and End Results (SEER) Program collects data on cancer incidence and treatments given as the first course of therapy. Medicare claims are another source of cancer treatment-related information. We assessed the agreement between these data sources to identify cancer surgery.</p><p><strong>Methods: </strong>We used the SEER-Medicare data to create a female breast and bladder cancer cohort that included patients diagnosed from 2004 to 2019 and continuously enrolled in Parts A/B fee-for-service from 4 months before at least 12 months following diagnosis, the window for surgery assessment. The presence/absence of Medicare surgery treatment claims was compared with SEER surgery data.</p><p><strong>Results: </strong>Of the 146,180 patients with breast cancer, 90.3% had surgery, and 6.4% did not have surgery per both SEER and Medicare. Surgery was identified in SEER only for 1.3% and in Medicare only for 1.6% (exact agreement=97%, κ=0.80). In the bladder cancer cohort (n=47,882), 90.9% had surgery and 1.8% did not, per both SEER and Medicare data. Surgery was recorded in SEER only for 2.2% and in Medicare only for 4.6% (exact agreement=93%, κ=0.31). For 0.1% of breast cancer patients and 0.3% of bladder cancer patients, surgery status was unknown per SEER, but Medicare surgery claims were present.</p><p><strong>Conclusions: </strong>Overall, there was high agreement between SEER and Medicare claims in identifying breast and bladder cancer surgery, but there were some patients who received bladder cancer surgery per Medicare but not per SEER. It is possible that patients received surgeries in the community setting, which were not reported to SEER.</p>","PeriodicalId":18364,"journal":{"name":"Medical Care","volume":" ","pages":"787-792"},"PeriodicalIF":1.9,"publicationDate":"2026-11-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC13418056/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"148536230","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":2,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Health-Related Social Needs and Health Care Access and Use by Payer Type.","authors":"Vivian Hsing-Chun Wang, Donglan Zhang, Diana Silver, José A Pagán","doi":"10.1097/MLR.0000000000002362","DOIUrl":"10.1097/MLR.0000000000002362","url":null,"abstract":"<p><strong>Background: </strong>While payers and health systems are increasingly interested in addressing health-related social needs (HRSNs) to reduce health care use and align with value-based care incentives and regulatory requirements, limited evidence enables actionable strategies to manage and address social needs across population groups.</p><p><strong>Objectives: </strong>To understand the relationship between HRSNs and health care access and use for adults with Medicare, Medicaid, and private health insurance coverage.</p><p><strong>Research design: </strong>Survey data from adult participants from the All of Us Research Program (2017-2023; n=126,490) and logistic regression were used to examine the association between food insecurity and housing instability and having a usual source of care, seeing a health care provider, and forgoing care due to cost-stratified by payer type.</p><p><strong>Results: </strong>The prevalence of HRSNs varied substantially by insurance: food insecurity affected 49.20% of Medicaid beneficiaries 18-64 years of age, 11.89% of privately insured adults 18-64 years of age, and 5.20% of Medicare beneficiaries 65 years of age and older; housing instability affected 54.61%, 25.18%, and 14.99%, respectively. Food insecurity was associated with lower odds of having a usual source of care for Medicaid and privately insured adults, lower odds of use for privately insured adults, and higher odds of forgone care for all 3 payer types. Housing instability was associated with lower odds of having a usual source of care for all 3 papers and with higher odds of forgone care for all groups.</p><p><strong>Conclusions: </strong>HRSNs like food insecurity and housing instability vary substantially by payer type and influence health care access and utilization in different ways. This can inform the design of payer-specific health management strategies that incorporate HRSNs.</p>","PeriodicalId":18364,"journal":{"name":"Medical Care","volume":" ","pages":"759-765"},"PeriodicalIF":1.9,"publicationDate":"2026-11-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"148713232","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":2,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"The Scope of Care Coordination for Older Adults Whose Dominant Provider Is a Nurse Practitioner Versus a Primary Care Physician.","authors":"Amy McMenamin, Monica O'Reilly-Jacob, Musarrat Nahid, Laura C Pinheiro, Monika Safford, Lisa M Kern","doi":"10.1097/MLR.0000000000002365","DOIUrl":"10.1097/MLR.0000000000002365","url":null,"abstract":"<p><strong>Background: </strong>Nurse practitioners (NPs) play an increasingly prominent role in primary care, particularly in low-income and rural communities. Yet the differences in care coordination demands between NP-dominant and physician-dominant primary care remain unknown. As the number of providers involved in a patient's care increases, the complexity of care coordination also increases.</p><p><strong>Objective: </strong>To determine if the scope of care coordination (ie, the number of other providers involved in a patient's care) varies by NP versus generalist physician.</p><p><strong>Methods: </strong>In 2425 participants from the nationwide Reasons for Geographic and Racial Differences in Stroke (REGARDS) study linked with 2013-2016 Medicare claims, we conducted a cross-sectional study using negative binomial regression analyses.</p><p><strong>Results: </strong>Our sample was 52.1% female with a mean age of 75.6 years. Participants with dominant NPs (n=146, 6%) were more likely to be dually eligible for Medicaid and reside in rural areas, but had fewer chronic conditions than those with dominant generalist physicians (n=2279, 94%). The median number of other unique providers involved in care was 4 (IQR=2-6) for NP-dominant patients versus 3 (IQR=2-6) for physician-dominant patients. After adjusting for covariates, those with dominant NPs had 19% more unique providers involved in their care (IRR=1.19, 95% CI: 1.07-1.32). Among participants with 5+ chronic conditions, participants with dominant NPs were seen by 31% more unique providers per year (IRR=1.31, 95% CI: 1.12-1.54).</p><p><strong>Conclusion: </strong>Older adults receiving NP-dominant primary care had a broader scope of care coordination than those receiving generalist physician-dominant primary care, especially among those with 5+ chronic conditions.</p>","PeriodicalId":18364,"journal":{"name":"Medical Care","volume":" ","pages":"793-800"},"PeriodicalIF":1.9,"publicationDate":"2026-11-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC13621388/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"148536253","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":2,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Continuity of Medications for Opioid Use Disorder in States With and Without Medicaid Prescription Cap Policies.","authors":"Patience M Dow, Miriam George, Landon D Hughes, Theresa I Shireman, Julie M Donohue, Christina M Andrews, Lisa Peterson, Jaclyn M W Hughto","doi":"10.1097/MLR.0000000000002366","DOIUrl":"10.1097/MLR.0000000000002366","url":null,"abstract":"<p><strong>Background: </strong>Medicaid prescription cap policies persist in 12 states; however, it is unclear how they affect the quality of opioid use disorder (OUD) treatment.</p><p><strong>Objectives: </strong>To examine the association between cap policies and the continuity in receipt of medication for OUD (MOUD) treatment in Medicaid.</p><p><strong>Methods: </strong>Using 2016-2021 T-MSIS Analytical Files data from 37 states, we identified nondual adult (18-64 y) Medicaid enrollees diagnosed with OUD who received MOUD. The exposure was the state's Medicaid prescription cap policy status. The main outcome was a binary variable for MOUD continuity, overall and by type, defined as no treatment gap exceeding 7 consecutive days during a 180-day observation period. We estimated risk ratios for MOUD continuity using modified Poisson regression models, adjusting for individual and state-level covariates to test associations.</p><p><strong>Results: </strong>Nearly half the sample was female, and the mean age was 37 years. MOUD continuity ranged from 40.7% to 44.3% in states without cap policies and 37.5%-39.6% in cap states. Compared with enrollees in noncap states, those in cap states had a 12% higher likelihood of experiencing at least 1 MOUD treatment gap [risk ratio (RR)=1.12; 95% CI: 1.12-1.13]. These findings were consistent for buprenorphine and methadone. Factors associated with overall MOUD discontinuity included younger age, male sex, living in nonmetropolitan areas, and having 3 or more comorbidities.</p><p><strong>Conclusions: </strong>Prescription caps were associated with reduced continuity of MOUD, overall and for buprenorphine and methadone, suggesting that revising or removing these policies could improve OUD quality metrics in Medicaid.</p>","PeriodicalId":18364,"journal":{"name":"Medical Care","volume":" ","pages":"801-810"},"PeriodicalIF":1.9,"publicationDate":"2026-11-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC13639984/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"148549624","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":2,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Impact of a Long-Term Benzodiazepine Use Prior Authorization Policy on Utilization and Non-Fatal Adverse Health Outcomes in a State Medicaid Program.","authors":"Daniel M Hartung, Sarah Servid, Luke Middleton, Tracy Klein, Jonah Geddes, Timothy S Anderson, Tae Woo Park","doi":"10.1097/MLR.0000000000002360","DOIUrl":"10.1097/MLR.0000000000002360","url":null,"abstract":"<p><strong>Background: </strong>Despite limited evidence of efficacy and well-established risks, long-term benzodiazepine use remains common. In July 2016, the Oregon Medicaid program introduced a prior authorization policy limiting benzodiazepine prescriptions to 4 weeks.</p><p><strong>Objectives: </strong>To evaluate the impact of Oregon's benzodiazepine policy on medication utilization and health outcomes.</p><p><strong>Research design: </strong>Interrupted time series regressions from January 2015-December 2017 (18 mo pre vs. post-policy).</p><p><strong>Subjects: </strong>Rolling cohorts of adult benzodiazepine recipients with 6 months of continuous enrollment before and after each month of observation.</p><p><strong>Measures: </strong>Benzodiazepine utilization included monthly measures of overall, prevalent long-term, and incident long-term medication use. Harms included a composite measure of emergency department or inpatient admissions for overdose, self-harm, acute withdrawal, or acute psychiatric events, and were compared with patients using similar medications that were not affected by the policy.</p><p><strong>Results: </strong>The study population included 69,143 benzodiazepine recipients; 68% were female, and the average age was 41 years or older. Following policy implementation, there was a significant segment decrease (-​​​29.82 recipients/1000 patients; 95% CI: -​​​33.75 to -​​​25.89) in incident long-term benzodiazepine use and a 1.17 recipients/1000 patients/month (95% CI: 0.82-1.52) increase in trend. Trends in prevalent long-term (-1.16 recipients/1000 patients/month: 95% CI: -1.32 to -0.99) benzodiazepine use also declined. Modest trend decreases in harm were observed among all cohorts.</p><p><strong>Conclusions: </strong>A policy to limit benzodiazepine duration was associated with a substantial reduction in progression to longer-term use and modest declines in the trend for potential harms.</p>","PeriodicalId":18364,"journal":{"name":"Medical Care","volume":" ","pages":"742-750"},"PeriodicalIF":1.9,"publicationDate":"2026-11-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"148620738","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":2,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Identifying Medication Discontinuations Using Text Searching and Clinical Data.","authors":"Glenn K Goodrich, Elizabeth A Bayliss, James Lagrotteria, Jennifer C Barrow, Bill Harding, Kathy S Gleason, Courtney R Kraus, Valerie Paolino, Jonathan D Norton, Orla C Sheehan, Linda A Weffald, Ariel R Green, Emily Reeve, Matthew L Maciejewski, Cynthia M Boyd","doi":"10.1097/MLR.0000000000002369","DOIUrl":"10.1097/MLR.0000000000002369","url":null,"abstract":"<p><strong>Background: </strong>Identifying clinically intended medication discontinuations at scale may help generate evidence to inform deprescribing. We developed an algorithmic approach to identifying such discontinuations, combining text strings applied to clinical documentation with medication order data for 5 different drug groups: oral hypoglycemics, statins, antihypertensives, bladder antimuscarinics, and antithrombotics.</p><p><strong>Design: </strong>The study population (n=1588) comprised individuals aged older than 65 with ≥90-day gaps in dispensing classified through manual review as having a clinically intended medication discontinuation or not. This gold-standard cohort was randomly divided into development and validation subsamples for each drug group. We developed text strings from clinical documentation reflecting clinical intent to discontinue a medication (or not). Text strings were usually simple [eg, \"stop (medication)\"], but required tailoring to drug groups [eg, temporarily \"hold (antithrombotic)\"]. Text strings queried clinical documentation and were supplemented with order discontinuation data, if available. We calculated sensitivity and specificity for identifying intended discontinuations for text alone, discrete data alone, and the full algorithm across validation samples.</p><p><strong>Results: </strong>Sensitivity and specificity for the full algorithm were 80% and 85% for oral hypoglycemics (n=467), 75% and 95% for statins (n=282), 82%, 75% for antihypertensives (n=599), 77% and 80% for bladder antimuscarinics (n=80), and 74% and 78% for antithrombotics (n=160). The full algorithm had higher sensitivity than either text or order data alone.</p><p><strong>Conclusions: </strong>Text-based approaches supplemented by medication order data can identify clinically intended medication discontinuations at scale with moderate specificity and sensitivity. This may reduce misclassification relative to using claims data to generate evidence about deprescribing.</p>","PeriodicalId":18364,"journal":{"name":"Medical Care","volume":" ","pages":"766-770"},"PeriodicalIF":1.9,"publicationDate":"2026-11-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC13488500/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"148727269","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":2,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Home Health Specialization and Postacute Outcomes.","authors":"Ilana Salant, Amanda C Chen, David C Grabowski","doi":"10.1097/MLR.0000000000002361","DOIUrl":"10.1097/MLR.0000000000002361","url":null,"abstract":"<p><strong>Background: </strong>Among traditional Medicare patients, discharge to home health agencies (HHAs) has become the most common postacute care (PAC) setting following hospitalization.</p><p><strong>Objectives: </strong>Estimate the effects of receiving care from home health agencies (HHAs) that specialize in providing PAC.</p><p><strong>Research design: </strong>Cross-sectional study using an instrumental variables approach with a differential distance between patients and specialized HHAs.</p><p><strong>Subjects: </strong>Using 100% Medicare fee-for-service claims, we identified 853,780 traditional Medicare patients receiving postacute home health care in 2019. Postacute episodes were defined as home health starting within 14 days of hospital discharge. The sample averaged 56% female, 20% dual-eligible, and 84% White. Patient demographic and clinical characteristics were mostly similar between those who received care at PAC-specialized and nonspecialized HHAs.</p><p><strong>Measures: </strong>HHAs were categorized as PAC-specialized if they were in the 75th percentile nationally for share of postacute episodes. Main outcomes included hospitalization, skilled nursing facility (SNF) use, and mortality during the home health spell and within 6 weeks of HHA discharge.</p><p><strong>Results: </strong>The instrument was strong (F-statistic=905.2), with each mile of differential distance reducing specialized HHA probability by 0.8 percentage points (pp). During home health spells, patients at specialized HHAs experienced significantly lower hospitalization risk (-2.1 pp) and SNF admissions (-0.3 pp). Postdischarge, we observed differences in hospitalizations (-0.8 pp during the discharge week and 0.9 pp at 6 wk post-HHA discharge). Mortality rates were consistently lower during the discharge week (-1.3 pp) and within 6 weeks postdischarge (-1.1 pp).</p><p><strong>Conclusions: </strong>Specialized HHAs appear to achieve better outcomes during treatment and have lower mortality rates both during and after care, suggesting important implications for postacute care delivery optimization.</p>","PeriodicalId":18364,"journal":{"name":"Medical Care","volume":" ","pages":"751-758"},"PeriodicalIF":1.9,"publicationDate":"2026-11-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"148579340","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":2,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Trade-Offs Between Patient Experience and Health Care Access: Comparing Veterans Health Administration Versus Community Care by Veteran Race and Ethnicity.","authors":"Michelle S Wong, W Neil Steers, Kimberly E Lind, Donna L Washington","doi":"10.1097/MLR.0000000000002368","DOIUrl":"10.1097/MLR.0000000000002368","url":null,"abstract":"<p><strong>Background: </strong>Racial and ethnic disparities in patient-reported experiences exist in the Veterans Health Administration (VA) and in VA-paid health care from non-VA providers (\"community care\"), but how these disparities compare is unknown.</p><p><strong>Objectives: </strong>We compared racial and ethnic disparities in patient-reported experiences between VA primary care and community care, and calculated differences in VA versus community care by patient race and ethnicity.</p><p><strong>Methods: </strong>Using cross-sectional data from the 2020 to 2023 VA Survey of Healthcare Experiences of Patients-VA Primary Care and Community Care surveys, we used linear and logistic regressions to assess patient-reported access, care coordination, communication, and provider satisfaction for each racial and ethnic group by setting, and calculated differences-in-differences by race and ethnicity and setting.</p><p><strong>Results: </strong>Primary care provided in community care had larger racial and ethnic disparities in patient-reported experiences of care than VA. Compared with White Veterans, age and sex-adjusted community care disparities exceeded VA disparities for communication among Black Veterans by 13 percentage points; care coordination for American Indian/Alaska Native, Black, and multirace Veterans by 22, 12, and 16 percentage points, respectively; and provider satisfaction for American Indian/Alaska Native Veterans by 34 percentage points.</p><p><strong>Conclusion: </strong>Our findings highlight potential unintended consequences of VA's efforts to improve timely access by increasing reliance on community care, which may inadvertently widen disparities and contribute to worse care experiences. We suggest several policy implications, including tailoring existing patient tools to navigate community care to minoritized groups experiencing disparities, and providing VA and CC metrics to Veterans to support informed decisions.</p>","PeriodicalId":18364,"journal":{"name":"Medical Care","volume":" ","pages":"818-827"},"PeriodicalIF":1.9,"publicationDate":"2026-11-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"148874364","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":2,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Machine Learning for Evaluating the Heterogeneous Effects of Intensive In-Hospital Rehabilitation During the Postacute Phase After Hip Fracture Surgery on Activities of Daily Living.","authors":"Takaaki Ikeda, Takuaki Tani, Upul Cooray, Yuta Suzuki, Yosuke Kimura, Kazuhiro Miyata, Masayasu Murakami, Ken Osaka, Kiyohide Fushimi","doi":"10.1097/MLR.0000000000002356","DOIUrl":"10.1097/MLR.0000000000002356","url":null,"abstract":"<p><strong>Background: </strong>It remains unclear which patient subgroups benefit most from intensive rehabilitation therapy.</p><p><strong>Objectives: </strong>This study aimed to examine the heterogeneity in the effects of intensive postacute rehabilitation after hip fracture surgery on activities of daily living and to identify its potential sources.</p><p><strong>Research design: </strong>A retrospective observational study.</p><p><strong>Subjects: </strong>Patients aged 50 years or older who underwent hip fracture surgery within 2 days of admission and were transferred to a rehabilitation ward between 7 and 30 days after surgery.</p><p><strong>Measures: </strong>Exposure was defined as the average daily rehabilitation time within 30 days posttransfer, dichotomized as ≥120 versus <120 minutes/day. The outcome was the motor domain score of the Functional Independence Measure (FIM) at 60 days posttransfer. Heterogeneity of treatment effects was assessed using conditional average treatment effects (CATEs) estimated through the causal forest approach. The models were adjusted for relevant covariates, including age, sex, and FIM score at the time of transfer to the rehabilitation ward.</p><p><strong>Results: </strong>The causal forest approach revealed heterogeneous effects-the estimated CATE for the top 20% high-benefit subgroup was 3.89 (95% CI: 2.32-5.46). The high-benefit subgroup was older and had lower FIM scores for the self-care, mobility, transfers, and excretion control domains at the time of transfer, compared with the low-benefit subgroup (the bottom 20% of the estimated CATEs).</p><p><strong>Conclusions: </strong>Heterogeneity exists in the association between intensive in-hospital rehabilitation therapy and functional status among older patients undergoing early hip fracture surgery during the postacute rehabilitation phase.</p>","PeriodicalId":18364,"journal":{"name":"Medical Care","volume":" ","pages":"725-732"},"PeriodicalIF":1.9,"publicationDate":"2026-11-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"148345386","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":2,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Comparative Evaluation of State-Level Subscription-Based Payment Models for Hepatitis C Drugs.","authors":"Zizi Elsisi, Jing Li, H Nina Kim, Anirban Basu","doi":"10.1097/MLR.0000000000002359","DOIUrl":"10.1097/MLR.0000000000002359","url":null,"abstract":"<p><strong>Background: </strong>Subscription-based payment models (SBPMs) have been adopted to expand access to hepatitis C virus (HCV) treatment within Medicaid programs.</p><p><strong>Objective: </strong>To evaluate the impact of SBPMs on HCV screening, RNA testing, and direct-acting antiviral (DAA) uptake among Medicaid Managed Care enrollees in Louisiana and Washington, and to identify factors associated with differential policy effects.</p><p><strong>Research design: </strong>Quasi-experimental study using the synthetic control method to compare outcomes in Louisiana and Washington-the only states implementing SBPMs in July 2019-with weighted combinations of 14 control states.</p><p><strong>Subjects: </strong>Adults aged 18-64 years or older enrolled in Medicaid Managed Care between January 2018 and December 2022.</p><p><strong>Measures: </strong>Monthly HCV screening, RNA testing, DAA initiation, and refill rates identified from payer-complete closed claims.</p><p><strong>Results: </strong>Louisiana SBPM was associated with significant increases in RNA testing (+35.2/100,000 persons/mo), DAA initiation (+7.8/1000 patients/mo), and DAA refills (+24.4/1000 patients/mo; all P =0.07). Gains were broad-based across subgroups and geographically consistent. Washington SBPM was associated with nonsignificant screening changes and significant declines in DAA initiation (-3.6/1000 patients/mo) and refills (-12.9/1000 patients/mo; P =0.07), with uniformly negative or null subgroup effects.</p><p><strong>Conclusions: </strong>SBPM yielded markedly different outcomes across states. Louisiana gains likely reflect convergence with recent Medicaid expansion and prior removal of DAA restrictions, generating a large treatment-eligible pool at implementation. Washington earlier expansion (2014) and fibrosis-restriction removal (2016) may have already addressed this demand. As the federal government invests $12.3 billion in HCV elimination with SBPM as a central mechanism, payment reform must be paired with comprehensive strategies-including provider engagement, screening infrastructure, and patient navigation-to achieve elimination goals.</p>","PeriodicalId":18364,"journal":{"name":"Medical Care","volume":" ","pages":"733-741"},"PeriodicalIF":1.9,"publicationDate":"2026-11-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"148579329","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":2,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}