Health Services Research最新文献

{"title":"Quantifying Nurse and Physician Clinical Performance for Mechanically Ventilated Patients","authors":"Christopher F. Chesley,&nbsp;Yingying Lu,&nbsp;Rachel Kohn,&nbsp;Hayley B. Gershengorn,&nbsp;Kelly C. Vranas,&nbsp;Catherine L. Hough,&nbsp;Olga Yakusheva,&nbsp;Deena Kelly Costa,&nbsp;Deanna J. Marriott,&nbsp;David A. Asch,&nbsp;Aerielle Belk,&nbsp;Stefania Scott,&nbsp;Wei Wang,&nbsp;Meeta Kerlin","doi":"10.1111/1475-6773.70153","DOIUrl":"10.1111/1475-6773.70153","url":null,"abstract":"<div>\u0000 \u0000 \u0000 <section>\u0000 \u0000 <h3> Objective</h3>\u0000 \u0000 <p>Expanding on previous research applying value-added modeling to clinician performance measurement, we quantified simultaneous nurse and physician performance among mechanically ventilated patients.</p>\u0000 </section>\u0000 \u0000 <section>\u0000 \u0000 <h3> Study Setting and Design</h3>\u0000 \u0000 <p>In a retrospective cohort spanning five academic hospitals, we used multiple linear regression to determine relationships between nurse and physician assignments and changes in patient illness severity (Laboratory-based Acute Physiology Score) during intensive care unit (ICU) admission. Individual clinician performance was derived from regression coefficients. Collective clinician contribution to disease severity variance was assessed by comparing the coefficient of determination across clinician-only and joint-clinician models. Consistency of clinician performance estimates was cross-validated using random 1:1 partitions of the patient population using Pearson's correlation.</p>\u0000 </section>\u0000 \u0000 <section>\u0000 \u0000 <h3> Data Sources and Analytic Sample</h3>\u0000 \u0000 <p>Electronic health record data were extracted from mechanically ventilated patients at study ICUs between 2018 and 2022.</p>\u0000 </section>\u0000 \u0000 <section>\u0000 \u0000 <h3> Principal Findings</h3>\u0000 \u0000 <p>Among 17,082 clinical encounters, 215 physicians, and 1719 nurses, nurse and physician assignments improved model fit. Together, they attributed 7% of variability in disease severity trajectory; separately, nurse assignments accounted for greater variance than physician assignments (6% vs. 4%, respectively). Cross-partition clinician performance was moderately correlated (<i>r</i> = 0.31 [nurses]<i>, r</i> = 0.4 [physicians], <i>p</i> &lt; 0.001 for both comparisons).</p>\u0000 </section>\u0000 \u0000 <section>\u0000 \u0000 <h3> Conclusions</h3>\u0000 \u0000 <p>Individual nurse and physician care independently contribute to disease severity trajectory among mechanically ventilated patients.</p>\u0000 </section>\u0000 </div>","PeriodicalId":55065,"journal":{"name":"Health Services Research","volume":"61 4","pages":""},"PeriodicalIF":3.0,"publicationDate":"2026-07-29","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://onlinelibrary.wiley.com/doi/epdf/10.1111/1475-6773.70153","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"148609552","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":"Modernizing the Front Door to Care: Evaluation of Veterans Administration Health Connect's Impact on Access, Utilization, and Patient Experience","authors":"Anita A. Vashi,&nbsp;Liam Rose,&nbsp;Tracy Urech,&nbsp;Allison Engstrom Buggaveeti,&nbsp;Linda Diem Tran","doi":"10.1111/1475-6773.70151","DOIUrl":"https://doi.org/10.1111/1475-6773.70151","url":null,"abstract":"<div>\u0000 \u0000 \u0000 <section>\u0000 \u0000 <h3> Objective</h3>\u0000 \u0000 <p>To evaluate whether centralized appointment scheduling and same-day virtual clinician evaluation improved appointment timeliness and follow-up after nurse triage. We also assessed whether these changes were associated with differences in downstream utilization, costs, reach, and Veteran experience.</p>\u0000 </section>\u0000 \u0000 <section>\u0000 \u0000 <h3> Study Setting and Design</h3>\u0000 \u0000 <p>Retrospective quasi-experimental evaluation of Veteran Administration Health Connect (VAHC) modernization across 18 regions between October 1, 2018, and September 30, 2024. Staggered rollout enabled difference-in-differences and event-study analyses comparing outcomes before and after modernization.</p>\u0000 </section>\u0000 \u0000 <section>\u0000 \u0000 <h3> Data Sources and Analytic Sample</h3>\u0000 \u0000 <p>Data were drawn from the Veterans Administration Corporate Data Warehouse, Telecare Record Manager, and Customer Relationship Management platforms, and VSignals Veteran experience surveys. The analytic sample comprised 11,118,916 encounters (4,560,677 pre-modernization; 6,558,239 post-modernization).</p>\u0000 </section>\u0000 \u0000 <section>\u0000 \u0000 <h3> Principal Findings</h3>\u0000 \u0000 <p>Centralized scheduling was associated with modest and mixed improvements in appointment access. Same-day scheduling increased by 14.3 percentage points (95% CI, 10.1 to 18.5). Time from call to scheduled appointment decreased by 0.37 days (95% CI, −0.49 to −0.26), while time to completed appointment increased by 2.9 days (95% CI, 0.2 to 5.7). Following modernization, time from nurse triage to any subsequent care decreased by 0.28 days (95% CI, −0.45 to −0.11), and the proportion of callers receiving no follow-up care within 7 days declined by 2.3 points (95% CI, −4.0 to −0.5). Modernization was not associated with changes in the proportion of all emergency department (ED) visits preceded by a nurse triage call or in total ED visit volume. Seven-day ED visits, admissions, and total costs did not change meaningfully. Veteran satisfaction was high for post-modernization virtual encounters.</p>\u0000 </section>\u0000 \u0000 <section>\u0000 \u0000 <h3> Conclusions</h3>\u0000 \u0000 <p>VAHC modernization improved appointment access and follow-up after nurse triage but was not associated with short-term changes in ED use or costs, highlighting gains in navigation and experience without immediate shifts in downstream utilization.</p>\u0000 </section>\u0000 </div>","PeriodicalId":55065,"journal":{"name":"Health Services Research","volume":"61 4","pages":""},"PeriodicalIF":3.0,"publicationDate":"2026-07-18","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"148467684","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":"Are the Best Worth the Wait? Physician Quality Scores and Access Delays","authors":"Yi-Jung Shen,&nbsp;Samantha G. Auty,&nbsp;Kevin N. Griffith","doi":"10.1111/1475-6773.70148","DOIUrl":"10.1111/1475-6773.70148","url":null,"abstract":"<div>\u0000 \u0000 \u0000 <section>\u0000 \u0000 <h3> Objective</h3>\u0000 \u0000 <p>The Veterans Health Administration's (VHA) Community Care Network generally includes physicians with higher Medicare Merit-Based Incentive Payment System (MIPS) quality scores than nonparticipants, yet veterans disproportionately receive care from participating physicians with lower scores. Whether physician quality or availability influences veterans' use of community care has not been comprehensively evaluated. Our objective was to assess whether VHA community care specialists with higher MIPS quality scores receive greater referral volume or have longer wait times.</p>\u0000 </section>\u0000 \u0000 <section>\u0000 \u0000 <h3> Study Setting and Design</h3>\u0000 \u0000 <p>We used multivariate regression models to assess the associations between physicians' MIPS quality scores, ranging from 0 to 100, and wait times or referral volumes. We also tested whether wait time moderated the association between physician quality and referral volume.</p>\u0000 </section>\u0000 \u0000 <section>\u0000 \u0000 <h3> Data Sources and Analytic Sample</h3>\u0000 \u0000 <p>We used administrative data to identify referrals to community-based specialists during 2021–2022. Referrals were then merged with MIPS quality scores from the Centers for Medicare &amp; Medicaid Services using national provider identifiers.</p>\u0000 </section>\u0000 \u0000 <section>\u0000 \u0000 <h3> Principal Findings</h3>\u0000 \u0000 <p>Our sample included 83,911 specialty care referrals involving 43,736 specialists. The mean MIPS quality score was 81.9 (SD = 20.9), including 77.9% of physicians who scored ≥ 75, the threshold for a positive payment adjustment. The overall mean wait time was 21.8 days (SD = 22.0), and the mean referral volume was 6.6 per year (SD = 10.5). In covariate-adjusted regression models, MIPS scores were not associated with wait times (+0.12 days per 10-point increase, 95% CI: −0.02, 0.25) or referral volumes (−0.15 referrals per 10-point increase, 95% CI: −0.37, 0.06). Wait time did not significantly moderate the relationship between MIPS score and referral volume.</p>\u0000 </section>\u0000 \u0000 <section>\u0000 \u0000 <h3> Conclusion</h3>\u0000 \u0000 <p>Physician quality appears to play a limited role in shaping referral decisions or access patterns in VHA community care. Although higher-scoring physicians sometimes have slightly longer wait times, these differences are small and do not translate into higher referral volumes.</p>\u0000 </section>\u0000 </div>","PeriodicalId":55065,"journal":{"name":"Health Services Research","volume":"61 4","pages":""},"PeriodicalIF":3.0,"publicationDate":"2026-07-09","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://onlinelibrary.wiley.com/doi/epdf/10.1111/1475-6773.70148","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"148414042","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":"Who Pays, Who Gains? ACA Medicaid Expansions and Changes in Net Income and Tax Liability by Socioeconomic Status","authors":"Matthew Hui Liu,&nbsp;Rebecca Anna Schut","doi":"10.1111/1475-6773.70147","DOIUrl":"10.1111/1475-6773.70147","url":null,"abstract":"<div>\u0000 \u0000 \u0000 <section>\u0000 \u0000 <h3> Objective</h3>\u0000 \u0000 <p>To evaluate the effects of Affordable Care Act (ACA) Medicaid expansions on changes to net (after-tax) income and federal tax liability across socioeconomic status (SES).</p>\u0000 </section>\u0000 \u0000 <section>\u0000 \u0000 <h3> Study Setting and Design</h3>\u0000 \u0000 <p>Event study and difference-in-difference analyses assessed the effects of state-level ACA Medicaid expansions post-2020 on net income and federal tax liability.</p>\u0000 </section>\u0000 \u0000 <section>\u0000 \u0000 <h3> Data Sources and Analytic Sample</h3>\u0000 \u0000 <p>Analyses were performed on nationally-representative survey data from the 2010 to 2023 Integrated Public Use Microdata Series Current Population Survey (IPUMS CPS) Annual Social and Economic Supplement (ASEC). We restricted the sample to individuals aged 18–65 with known information on sociodemographic characteristics.</p>\u0000 </section>\u0000 \u0000 <section>\u0000 \u0000 <h3> Principal Findings</h3>\u0000 \u0000 <p>Medicaid expansions contributed to overall net income growth (2.10%, 95% CI 1.31–2.89). By socioeconomic status, postexpansion net incomes were higher among individuals in the lowest income quintile (3.56%, 1.47–5.65), among those employed in low (4.90%, 2.74–7.07), low-mid (2.05%, 0.57–3.54), and mid-high (1.97%, 0.61–3.32) skill occupations, and among those with less than a high school degree (3.51%, 0.50–6.51), some college (3.39%, 1.47–5.32), or a bachelor's degree (1.94%, 0.32–3.56). Results further show an increase in overall federal tax liability after deductions (3.84%, 2.43–5.25), namely among individuals in the second (5.20%, 0.72–9.68) and third (4.58%, 2.31–6.86) income quintiles, among those in low (6.99%, 2.78–11.20), low-mid (6.82%, 4.05–9.60), and mid-high (2.71%, 0.42–5.01) skill occupations, and among those with a high school degree or GED (4.79%, 1.97–7.60) or a master's degree (7.99%, 3.70–12.28).</p>\u0000 </section>\u0000 \u0000 <section>\u0000 \u0000 <h3> Conclusions</h3>\u0000 \u0000 <p>Findings suggest ACA Medicaid expansions induced downstream net income gains while increasing overall federal tax revenue. Results further suggest that the increased costs of Medicaid expansion are not largely borne by higher SES groups. Broadly, Medicaid expansions may provide substantial economic benefits to the entire U.S. population.</p>\u0000 </section>\u0000 </div>","PeriodicalId":55065,"journal":{"name":"Health Services Research","volume":"61 4","pages":""},"PeriodicalIF":3.0,"publicationDate":"2026-07-08","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://onlinelibrary.wiley.com/doi/epdf/10.1111/1475-6773.70147","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"148406855","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":"Attrition of the Midwifery Workforce: Understanding Factors Associated With Leaving the Profession","authors":"E. Brie Thumm,&nbsp;Amy H. Goh,&nbsp;Elizabeth G. Phillips,&nbsp;Zachary Giano","doi":"10.1111/1475-6773.70143","DOIUrl":"10.1111/1475-6773.70143","url":null,"abstract":"&lt;div&gt;\u0000 \u0000 \u0000 &lt;section&gt;\u0000 \u0000 &lt;h3&gt; Objective&lt;/h3&gt;\u0000 \u0000 &lt;p&gt;To understand why advanced practice midwives (certified nurse-midwives and certified midwives) leave the workforce.&lt;/p&gt;\u0000 &lt;/section&gt;\u0000 \u0000 &lt;section&gt;\u0000 \u0000 &lt;h3&gt; Study Setting and Design&lt;/h3&gt;\u0000 \u0000 &lt;p&gt;A multi-method, multi-source investigation included secondary analysis of certification data of advanced practice midwives and a cross-sectional online survey with closed- and open-ended items. Advanced practice midwives' active certification data were used to compare self-reported demographic characteristics of advanced practice midwives who reported working in the discipline of midwifery to those who did not (&lt;i&gt;n&lt;/i&gt; = 9704). A survey was conducted in 2022 with individuals who allowed their certification to lapse between 2017 and 2021 (&lt;i&gt;n&lt;/i&gt; = 303) and individuals who maintained certification but reported not working in the discipline of midwifery (&lt;i&gt;n&lt;/i&gt; = 1994) to understand why individuals left the workforce and the likelihood of returning. Data were analyzed with ANOVAs, chi-squares, &lt;i&gt;t&lt;/i&gt;-tests, and thematic analysis.&lt;/p&gt;\u0000 &lt;/section&gt;\u0000 \u0000 &lt;section&gt;\u0000 \u0000 &lt;h3&gt; Data Sources and Analytic Sample&lt;/h3&gt;\u0000 \u0000 &lt;p&gt;Administrative data from the American Midwifery Certification Board (&lt;i&gt;n&lt;/i&gt; = 9704) and an online survey from a national sample of currently and previously certified nurse-midwives and certified midwives who had left the workforce (&lt;i&gt;n&lt;/i&gt; = 646; response rate of 33.8%).&lt;/p&gt;\u0000 &lt;/section&gt;\u0000 \u0000 &lt;section&gt;\u0000 \u0000 &lt;h3&gt; Principal Findings&lt;/h3&gt;\u0000 \u0000 &lt;p&gt;The most endorsed reasons for leaving were work-life balance (50.3%, &lt;i&gt;n&lt;/i&gt; = 325), unsupportive work environment (34.7%, &lt;i&gt;n&lt;/i&gt; = 224), and schedule (32.0%, &lt;i&gt;n&lt;/i&gt; = 207). Participants from restrictive regulation states reported lack of opportunities for career advancement, state-level regulation restricting ability to practice, and lack of employment opportunities at higher rates. Respondents of color more frequently reported inadequate compensation, lack of opportunity for advancement, and workplace discrimination at higher rates. Themes included barriers to re-entry to practice and compensation.&lt;/p&gt;\u0000 &lt;/section&gt;\u0000 \u0000 &lt;section&gt;\u0000 \u0000 &lt;h3&gt; Conclusions&lt;/h3&gt;\u0000 \u0000 &lt;p&gt;Work-life balance and work environment drive midwifery workforce attrition. Individuals of color and those living in states with restrictive regulation face unique challenges. Challenges re-entering the workforce after leaving create barriers to remaining in the workforce, especially with inequitable compensation.&lt;/p&gt;\u0000 &lt;/section&gt;\u0000 &lt;/di","PeriodicalId":55065,"journal":{"name":"Health Services Research","volume":"61 4","pages":""},"PeriodicalIF":3.0,"publicationDate":"2026-07-07","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://onlinelibrary.wiley.com/doi/epdf/10.1111/1475-6773.70143","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"148400014","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":"Engaging Families in Pediatric Care Management: A Qualitative Study From the North Carolina Integrated Care for Kids Model","authors":"Hartlee Lidsky,&nbsp;Eleanor Wertman,&nbsp;Hadiya B. Sadiq,&nbsp;Greeshma James,&nbsp;Kimberlin Neblett,&nbsp;Tara Ilsley,&nbsp;Chelsea Swanson,&nbsp;Kori B. Flower,&nbsp;Michael Steiner,&nbsp;Carolyn Avery,&nbsp;Rushina Cholera","doi":"10.1111/1475-6773.70129","DOIUrl":"10.1111/1475-6773.70129","url":null,"abstract":"<div>\u0000 \u0000 \u0000 <section>\u0000 \u0000 <h3> Objective</h3>\u0000 \u0000 <p>To describe factors influencing caregiver engagement in pediatric care management.</p>\u0000 </section>\u0000 \u0000 <section>\u0000 \u0000 <h3> Study Setting and Design</h3>\u0000 \u0000 <p>This qualitative descriptive study of family engagement was based in the North Carolina Integrated Care for Kids (NC InCK) care management model. NC InCK proactively offers assistance with healthcare coordination and health-related social needs to Medicaid-insured children in five North Carolina counties. Participants were randomly recruited from three cohorts with different levels of engagement (never engaged, briefly engaged, and retained) and participated in semi-structured virtual interviews to understand barriers and facilitators to both enrollment and retention in care management. Cross-cohort themes were identified using rapid qualitative analysis.</p>\u0000 </section>\u0000 \u0000 <section>\u0000 \u0000 <h3> Data Sources and Analytic Sample</h3>\u0000 \u0000 <p>Interviews were conducted between May 2024 and January 2025 with 50 NC InCK-eligible English-speaking families.</p>\u0000 </section>\u0000 \u0000 <section>\u0000 \u0000 <h3> Principal Findings</h3>\u0000 \u0000 <p>Most participants were mothers (<i>n</i> = 38, 74%) and grandmothers (<i>n</i> = 6, 12%) of non-Hispanic Black children (<i>n</i> = 32, 64%). Initial enrollment facilitators included clear, genuine explanations of care management tailored to family needs. Enrollment obstacles included high caregiver self-reliance, confusion around program scope, and negative prior experiences with social service programs. Retention facilitators included flexible scheduling, convenient communication, and strong interpersonal relationships with care managers. Retention obstacles included competing demands, communication challenges, evolution of family needs, and misalignment between caregiver expectations and services. Post-interview, 32% of briefly engaged and 73% of never engaged participants requested re-enrollment in the NC InCK model.</p>\u0000 </section>\u0000 \u0000 <section>\u0000 \u0000 <h3> Conclusions</h3>\u0000 \u0000 <p>Care management is a fundamental pediatric population health strategy, but low family engagement limits large-scale implementation and impact. Strategies to increase participation include clear messaging and simplified eligibility criteria to effectively convey care management benefits. Strong care manager communication skills are needed to build relationships with caregivers from varied backgrounds. Evolving family needs and bandwidth necessitate flexible care management options rather than a one-size-fits-all model.</p>\u0000 </section>\u0000 </div>","PeriodicalId":55065,"journal":{"name":"Health Services Research","volume":"61 4","pages":""},"PeriodicalIF":3.0,"publicationDate":"2026-07-06","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"148392530","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 Effect of Hospital-Physician Vertical Integration on Utilization-Driven Changes in Healthcare Spending for an All-Payer Population With Multiple Chronic Conditions","authors":"Alexandra Harris,&nbsp;Neil Jordan,&nbsp;Cynthia Barnard,&nbsp;Jeffrey A. Linder,&nbsp;Brady Post","doi":"10.1111/1475-6773.70144","DOIUrl":"10.1111/1475-6773.70144","url":null,"abstract":"<div>\u0000 \u0000 \u0000 <section>\u0000 \u0000 <h3> Objective</h3>\u0000 \u0000 <p>To estimate the effect of hospital-physician vertical integration on utilization-driven annual healthcare spending for an all-payer cohort of patients with multiple chronic conditions.</p>\u0000 </section>\u0000 \u0000 <section>\u0000 \u0000 <h3> Study Setting and Design</h3>\u0000 \u0000 <p>We used a quasi-experimental difference-in-differences with staggered adoption approach to estimate the effect of hospital-physician vertical integration on total annual utilization-driven spending per patient (primary outcome). We also examined changes in annual inpatient, outpatient, professional, and pharmaceutical utilization-driven spending (secondary outcomes).</p>\u0000 </section>\u0000 \u0000 <section>\u0000 \u0000 <h3> Data Sources and Analytic Sample</h3>\u0000 \u0000 <p>Using 2016–2021 Virginia all-payer administrative claims data, we conducted a retrospective analysis of 77,248 patients aged 45–99, with Medicare, Medicaid, and/or commercial insurance, and at least two qualifying chronic conditions at the beginning of the study period. The treatment group included patients of physicians who began the study period independent and became integrated in 2018, 2019, 2020, or 2021, respectively. The control group included patients of physicians who remained independent during the entire study period.</p>\u0000 </section>\u0000 \u0000 <section>\u0000 \u0000 <h3> Principal Findings</h3>\u0000 \u0000 <p>While we found no significant difference in utilization-driven spending after integration overall ($1063, CI: $-364 to $2414), meaningful heterogeneity emerged across the staggered integration cohorts. Notably, when excluding the 2021 integration cohort (which exhibited significantly lower total annual utilization-driven spending), we found evidence of substantially higher annual total ($1750, CI: $207 to $3739) and inpatient ($898, CI: $65 to $2293) spending after integration among the earlier integration cohorts, driven by inpatient utilization. These findings held when limiting our analyses to patients of primary care physicians.</p>\u0000 </section>\u0000 \u0000 <section>\u0000 \u0000 <h3> Conclusions</h3>\u0000 \u0000 <p>This study provides evidence that the timing of hospital-physician vertical integration (pre-pandemic versus pandemic-era), particularly among primary care physicians, drove heterogeneous treatment effects in utilization-driven spending for the growing population of adults living with multiple chronic conditions.</p>\u0000 </section>\u0000 </div>","PeriodicalId":55065,"journal":{"name":"Health Services Research","volume":"61 4","pages":""},"PeriodicalIF":3.0,"publicationDate":"2026-07-06","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://onlinelibrary.wiley.com/doi/epdf/10.1111/1475-6773.70144","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"148392559","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":"Understanding Medicaid Estate Recovery: The Experience of North Carolina and Policy Implications for Future Reforms","authors":"Amanda Spishak-Thomas,&nbsp;Emma Sandoe,&nbsp;Heather Howard","doi":"10.1111/1475-6773.70141","DOIUrl":"https://doi.org/10.1111/1475-6773.70141","url":null,"abstract":"<div>\u0000 \u0000 \u0000 <section>\u0000 \u0000 <h3> Objective</h3>\u0000 \u0000 <p>To estimate the prevalence of Medicaid estate recovery in North Carolina.</p>\u0000 </section>\u0000 \u0000 <section>\u0000 \u0000 <h3> Study Setting and Design</h3>\u0000 \u0000 <p>We descriptively analyzed the number of estates, amount recovered, and hardship waiver applications using North Carolina public records data.</p>\u0000 </section>\u0000 \u0000 <section>\u0000 \u0000 <h3> Data Sources and Analytic Sample</h3>\u0000 \u0000 <p>The data contained information on the number of estates and amount recovered through Medicaid estate recovery between 2017 and 2021 (<i>n</i> = 2975). Additionally, we analyzed hardship waiver application data for residents who applied and had their application processed between 2018 and 2021 (<i>n</i> = 301).</p>\u0000 </section>\u0000 \u0000 <section>\u0000 \u0000 <h3> Principal Findings</h3>\u0000 \u0000 <p>We found approximately $83 billion was recovered from beneficiaries between 2017 and 2021, or 0.6% of the total cost of North Carolina's annual Medicaid program and just 0.9% of the fee-for-service annual long-term services and supports Medicaid budget. We found that Black homeowners were more likely to have lower value estates recovered, and overall, more money was recovered from white estates.</p>\u0000 </section>\u0000 \u0000 <section>\u0000 \u0000 <h3> Conclusion</h3>\u0000 \u0000 <p>While states hope Medicaid estate recovery may balance Medicaid spending through increased revenue, our findings demonstrate that these efforts may be insufficient. Policymakers should opt for strategies outside of the Medicaid program that can more precisely target high-net-worth individuals instead of policies like estate recovery that disproportionately impact low-income families.</p>\u0000 </section>\u0000 </div>","PeriodicalId":55065,"journal":{"name":"Health Services Research","volume":"61 3","pages":""},"PeriodicalIF":3.2,"publicationDate":"2026-06-13","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://onlinelibrary.wiley.com/doi/epdf/10.1111/1475-6773.70141","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"148238163","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":"Racial Disparities and Personal Responsibility Incentives in Medicaid","authors":"David M. Craig,&nbsp;Elaine M. Hernandez,&nbsp;Elizabeth M. Anderson,&nbsp;Yvette H. Tran,&nbsp;Erik S. Parker,&nbsp;Justin Blackburn,&nbsp;Sumedha Gupta","doi":"10.1111/1475-6773.70139","DOIUrl":"10.1111/1475-6773.70139","url":null,"abstract":"<div>\u0000 \u0000 \u0000 <section>\u0000 \u0000 <h3> Objective</h3>\u0000 \u0000 <p>To determine whether personal responsibility incentives in Medicaid differentially affect enrollment and the comprehensiveness of plan benefits among members who are non-Hispanic Black and non-Hispanic White.</p>\u0000 </section>\u0000 \u0000 <section>\u0000 \u0000 <h3> Study Setting and Design</h3>\u0000 \u0000 <p>We conducted an interrupted time series analysis to estimate trends in racial disparity ratios of enrollment across more comprehensive Healthy Indiana Plans (HIP) before and during the COVID-19 Public Health Emergency (PHE) when the state suspended personal responsibility incentives, including monthly premium contributions.</p>\u0000 </section>\u0000 \u0000 <section>\u0000 \u0000 <h3> Data Sources and Analytic Sample</h3>\u0000 \u0000 <p>We analyzed restricted-access administrative data from the Indiana Family and Social Services Administration from 2018 through 2023. The analytic cohort comprised 939,667 non-Hispanic Black and non-Hispanic White adults (19–64 years) enrolled in one of four HIP tiers, including HIP Plus or HIP Basic, and HIP State Plan Plus or HIP State Plan Basic in which presence of a qualifying health condition is required for eligibility.</p>\u0000 </section>\u0000 \u0000 <section>\u0000 \u0000 <h3> Principal Findings</h3>\u0000 \u0000 <p>Before the PHE, members who are non-Hispanic Black were approximately 23 percentage points less likely to be in the more comprehensive HIP Plus plan relative to members who are non-Hispanic White. An increase in the disparity ratio of 0.076 points toward parity (95% CI, 0.054–0.097 points) for HIP Plus recipients was observed following suspension of personal responsibility incentives during the PHE. After an administrative upgrade of all HIP Basic recipients to HIP Plus plans during July 2021, this disparity ratio increased an additional 0.146 points from the start of the PHE (95% CI, 0.141–0.151 points) to 0.994 (95% CI, 0.993–0.994).</p>\u0000 </section>\u0000 \u0000 <section>\u0000 \u0000 <h3> Conclusions</h3>\u0000 \u0000 <p>Personal responsibility incentives in Medicaid are associated with substantial and persistent racial disparities in enrollment and plan comprehensiveness. The study indicates that while the temporary removal of these incentives can reduce disparities, proactive policy interventions may be necessary to achieve and maintain equitable access to care.</p>\u0000 </section>\u0000 </div>","PeriodicalId":55065,"journal":{"name":"Health Services Research","volume":"61 3","pages":""},"PeriodicalIF":3.2,"publicationDate":"2026-06-10","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://onlinelibrary.wiley.com/doi/epdf/10.1111/1475-6773.70139","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"148221079","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":"Under-Documentation of Z-Codes in Hospitalizations of Homeless Shelter Users in New York City","authors":"Laila Alsabahi,&nbsp;Anna Zhilkova,&nbsp;Matthew Baker,&nbsp;Duncan Maru,&nbsp;Tsu-Yu Tsao","doi":"10.1111/1475-6773.70142","DOIUrl":"10.1111/1475-6773.70142","url":null,"abstract":"<div>\u0000 \u0000 \u0000 <section>\u0000 \u0000 <h3> Objective</h3>\u0000 \u0000 <p>To assess documentation of social risk International Classification of Diseases, 10th Revision (ICD-10) Z-codes among hospitalized homeless shelter users in New York City (NYC).</p>\u0000 </section>\u0000 \u0000 <section>\u0000 \u0000 <h3> Study Setting and Design</h3>\u0000 \u0000 <p>Cross-sectional analysis of hospitalizations among individuals experiencing homelessness using 2019 statewide administrative data from New York.</p>\u0000 </section>\u0000 \u0000 <section>\u0000 \u0000 <h3> Data Sources and Analytic Sample</h3>\u0000 \u0000 <p>New York Statewide Planning and Research Cooperative System (SPARCS) inpatient discharge data linked to NYC homeless shelter addresses. Hospitalizations were identified by matching geocoded discharge addresses to shelter locations (<i>n</i> = 13,105).</p>\u0000 </section>\u0000 \u0000 <section>\u0000 \u0000 <h3> Principal Findings</h3>\u0000 \u0000 <p>Among 13,105 hospitalizations, 27% had at least one Z-code documented and 23% included a homelessness Z-code. In adjusted analyses accounting for hospital-level clustering, documentation was highest for mental and behavioral health hospitalizations and lowest for maternal health admissions. Documentation was lower among women, younger patients, racial and ethnic minority groups, privately insured patients, and patients treated in private nonacademic hospitals.</p>\u0000 </section>\u0000 \u0000 <section>\u0000 \u0000 <h3> Conclusions</h3>\u0000 \u0000 <p>Z-code documentation among hospitalized individuals experiencing homelessness is low and varies across clinical, demographic, and institutional groups. Improving documentation completeness is important as reimbursement and equity-focused policies increasingly rely on accurate Z-code capture.</p>\u0000 </section>\u0000 </div>","PeriodicalId":55065,"journal":{"name":"Health Services Research","volume":"61 3","pages":""},"PeriodicalIF":3.2,"publicationDate":"2026-06-07","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://onlinelibrary.wiley.com/doi/epdf/10.1111/1475-6773.70142","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"148201353","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}