Health Services Research最新文献

{"title":"Understanding the Effect of Race on Medicare Advantage Enrollment.","authors":"Adam Atherly, Roger Feldman, Eline van den Broek-Altenburg, Bryan E Dowd","doi":"10.1111/1475-6773.14464","DOIUrl":"https://doi.org/10.1111/1475-6773.14464","url":null,"abstract":"<p><strong>Objective: </strong>To understand why Medicare Advantage (MA) has a relatively larger market share among racial minorities than traditional Medicare (TM).</p><p><strong>Study setting and design: </strong>We estimate Probit models for the choice of the MA sector versus TM by Black and Hispanic beneficiaries, as compared with White beneficiaries. We use a non-linear version of the Oaxaca-Blinder decomposition to decompose differences in the probability of MA enrollment by race into differences in explanatory variable values versus differences in the coefficients on those variables, which we identify as \"preferences\" for MA.</p><p><strong>Data sources and analytic sample: </strong>We combined 2020 Medicare Current Beneficiary Survey (MCBS) data with CMS data on MA plan payment levels aggregated to the county level, star ratings, and measures of market competition.</p><p><strong>Principal findings: </strong>In the Black/White beneficiary comparison, 83% of the 17% point difference in the probability of MA enrollment was explained by differences in preferences (p < 0.001) while only 17% was explained by differences in attributes (p < 0.05). In contrast, in the Hispanic/White beneficiary comparison, 72% of the difference was explained by differences in attributes (p < 0.001) and 28% was explained by differences in preferences (p < 0.01). Attributes associated with differing rates of MA enrollment by race included both market-level characteristics (e.g., payment levels) and personal characteristics (age, level of pain, and chronic disease count). Preferences associated with differing rates of MA enrollment included coefficients of sector characteristics such as payment rates and the number of four-star+ plans available and age.</p><p><strong>Conclusions: </strong>In this study, we find that the higher MA enrollment rate for Black versus White beneficiaries is largely associated with differences in preferences, while the higher enrollment rate for Hispanic beneficiaries is more associated with differences in attributes. Differences in preferences for MA sector characteristics were significant in explaining higher MA enrollment rates for both groups compared with White beneficiaries, suggesting that changes in payment rates will disproportionately impact racial minorities, particularly for Black beneficiaries. However, the reasons for different preferences for MA among racial groups remain somewhat of a puzzle, particularly given that we control for demographics, health, and market characteristics.</p>","PeriodicalId":55065,"journal":{"name":"Health Services Research","volume":" ","pages":"e14464"},"PeriodicalIF":3.1,"publicationDate":"2025-03-13","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"143626871","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":"Early Effects of Pathways to Success on Utilization in Traditional Medicare.","authors":"Meiling Ying, Addison Shay, John M Hollingsworth, Vahakn B Shahinian, Brent K Hollenbeck","doi":"10.1111/1475-6773.14597","DOIUrl":"https://doi.org/10.1111/1475-6773.14597","url":null,"abstract":"<p><strong>Objective: </strong>To evaluate the early effects of Pathways to Success implementation on utilization, as measured by quarterly price-standardized Medicare spending per beneficiary.</p><p><strong>Study setting and design: </strong>This study was a nationwide retrospective cohort analysis of Traditional Medicare beneficiaries. The primary outcome was overall utilization, as measured by adjusted quarterly price standardized spending per beneficiary. Secondary outcomes included adjusted quarterly price standardized spending by component type (inpatient, outpatient institutional, Part B, and skilled nursing facility). The primary independent variable is Pathways to Success implementation on July 1, 2019.</p><p><strong>Data sources and analytic sample: </strong>A 20% sample of national Medicare data from January 1, 2018, through March 31, 2020, includes Traditional Medicare beneficiaries managed in ACOs (n = 1,368,523) and outside of ACOs (\"controls,\" n = 1,476,982) prior to Pathways implementation.</p><p><strong>Principal findings: </strong>Unadjusted quarterly spending among those in ACOs and controls decreased over the study period by $13.5 (from $2614.8 before Pathways implementation to $2601.3 after Pathways implementation) and $89.8 (from $2723.1 before Pathways implementation to $2633.3 after Pathways implementation), respectively. Adjusted quarterly spending per beneficiary decreased more slowly in ACOs compared to controls (differences-in-differences estimate +$46.8 (95% CI $19.2, $74.4) in ACOs vs. controls). This difference was largely driven by a more rapid decrease in the utilization of inpatient care. Adjusted quarterly spending per beneficiary for inpatient care decreased more slowly in ACOs compared to controls (differences-in-differences estimate +$43.6 [95% CI $27.2, $60.0] in ACOs vs. controls).</p><p><strong>Conclusions: </strong>After Pathways, reductions in utilization, as measured by price-standardized spending, by ACOs occurred less rapidly than for those managed outside of the Shared Savings Program. This effect was driven by a more rapid decrease in spending for inpatient care by nonparticipants.</p>","PeriodicalId":55065,"journal":{"name":"Health Services Research","volume":" ","pages":"e14597"},"PeriodicalIF":3.1,"publicationDate":"2025-03-13","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"143626833","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":"Coordination and Integration of Providers Across Sectors Improves Referrals to and Connections With Services for Clients Engaged in Home Visiting.","authors":"Venice Ng Williams, Michael D Knudtson, Mandy A Allison, Gregory J Tung","doi":"10.1111/1475-6773.14457","DOIUrl":"https://doi.org/10.1111/1475-6773.14457","url":null,"abstract":"<p><strong>Objective: </strong>To examine the association between cross-sector collaboration among Nurse-Family Partnership (NFP) home visitors and service providers, and referrals to and use of services.</p><p><strong>Study setting and design: </strong>An observational study of 264 local NFP agencies in 40 states, the US Virgin Islands, DC, and tribal communities was conducted. Random intercept probit regressions examined provider-specific collaboration measures and their relationship with referrals to and use of services with that provider-type, adjusting for client-, nurse-, and agency-level covariates.</p><p><strong>Data sources and analytic sample: </strong>Secondary data from NFP implementation from 2015 to 2021 were matched to the 2018-2021 NFP Collaboration with Community Providers panel survey, 2010 Rural-Urban Commuting Area Codes, and the Index of Concentration at Extremes using 2010 census data. We included clients with their first NFP visit between January 2015 and December 2021 who completed visits through birth and did not cease program participation due to unaddressable reasons (n = 95,489).</p><p><strong>Principal findings: </strong>Provider-specific coordination with Early Intervention, mental health, crisis intervention, substance use treatment, and child health care promoted service referrals by 1.67% points [CI:1.08, 2.27], 2.14% points [CI:1.22, 3.06], 1.13% points [CI:0.60, 1.65], 0.86% [0.52, 1.21], and 1.13% points [CI:0.13, 2.12] respectively. Provider-specific integration promoted referrals to nutrition and housing resources by 0.08% points [CI:0.03, 0.14] and 0.98% points [CI:0.46, 1.51] respectively. Provider-specific coordination and integration were associated with families' utilization of nutrition by 1.03% points [CI:0.42, 1.65] and 0.21% points [CI:0.08, 0.35], housing resources by 1.28% points [CI:0.05, 2.50] and 0.93% points [CI:0.27, 1.60], Early Intervention by 3.11% points [CI:1.28, 4.94] and 0.45% points [CI:0.02, 0.89], and mental health services by 2.85% points [CI:1.70, 4.01] and 0.24% points [CI:0.03, 0.46]. Provider-specific relational coordination was associated with the use of substance use treatment by 3.19% points [CI:1.06, 5.32] and child health care by 1.47% points [CI:0.70, 2.23].</p><p><strong>Conclusions: </strong>Strong provider-specific collaboration is associated with increased referrals to and subsequent use of that service among families engaged in nurse home visiting, but this relationship varies by provider type.</p>","PeriodicalId":55065,"journal":{"name":"Health Services Research","volume":" ","pages":"e14457"},"PeriodicalIF":3.1,"publicationDate":"2025-03-07","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"143574703","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":"Medicaid at 60: Addressing Data Gaps.","authors":"Kirstin Blom, Joanne Jee, Kate Massey, Chris Park","doi":"10.1111/1475-6773.14463","DOIUrl":"https://doi.org/10.1111/1475-6773.14463","url":null,"abstract":"","PeriodicalId":55065,"journal":{"name":"Health Services Research","volume":" ","pages":"e14463"},"PeriodicalIF":3.1,"publicationDate":"2025-03-06","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"143568897","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":"Interdisciplinary Team-Based Intervention to Reduce Acute Care Utilization Among Emergency Department Multi-Visit Patients.","authors":"Yijung K Kim, Narae Park, Jenna H Everett, Lauren R Bangerter, Lucas C Carlson","doi":"10.1111/1475-6773.14458","DOIUrl":"https://doi.org/10.1111/1475-6773.14458","url":null,"abstract":"<p><strong>Objective: </strong>To evaluate the impact of the emergency department (ED) Multi-Visit Patient (MVP) Program, a novel team-based approach to supporting patients with frequent ED utilization.</p><p><strong>Study setting and design: </strong>The ED MVP Program identified patients with frequent ED visits, conducted comprehensive chart reviews, and implemented tailored care plans to address healthcare barriers and social determinants of health. A comparison group included eligible patients who did not receive the intervention as well as those not yet treated at a given month. We conducted a quasi-experimental study using difference-in-differences analysis with dynamic effects.</p><p><strong>Data sources and analytic sample: </strong>Acute care utilization (ED visits, observation stays, inpatient admissions) and 30-day readmission data were extracted from the electronic health record system across a multi-hospital not-for-profit healthcare system in the Baltimore-Washington metropolitan area.</p><p><strong>Principal findings: </strong>Compared with controls, patients receiving ED MVP intervention had 1.94 fewer acute care hospital visits (95% confidence interval [CI]: -2.54, -1.34) and 2.42 fewer days of acute care utilization (95% CI: -3.19, -1.64) in the following 12 months. There was also a small reduction in 30-day inpatient readmissions, averaging 0.08 fewer readmissions (95% CI: -0.16, -0.01).</p><p><strong>Conclusions: </strong>This study provides strong evidence for the effectiveness of a tailored care intervention to reduce acute care utilization among patients with frequent ED utilization.</p>","PeriodicalId":55065,"journal":{"name":"Health Services Research","volume":" ","pages":"e14458"},"PeriodicalIF":3.1,"publicationDate":"2025-03-06","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"143568952","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":"Comparison of Machine Learning Algorithms Identifying Children at Increased Risk of Out-of-Home Placement: Development and Practical Considerations.","authors":"Tyler J Gorham, Rose Y Hardy, David Ciccone, Deena J Chisolm","doi":"10.1111/1475-6773.14601","DOIUrl":"https://doi.org/10.1111/1475-6773.14601","url":null,"abstract":"<p><strong>Objective: </strong>To develop a machine learning (ML) algorithm capable of identifying children at risk of out-of-home placement among a Medicaid-insured population.</p><p><strong>Study setting and design: </strong>The study population includes children enrolled in a Medicaid accountable care organization between 2018 and 2022 in two nonurban Ohio counties served by the Centers for Medicare and Medicaid Services-funded Integrated Care for Kids Model. Using a retrospective cohort, we developed and compared a set of ML algorithms to identify children at risk of out-of-home placement within one year. ML algorithms tested include least absolute shrinkage and selection operator (LASSO)-regularized logistic regression and eXtreme gradient-boosted trees (XGBoost). We compared both modeling approaches with and without race as a candidate predictor. Performance metrics included the area under the receiver operating characteristic curve (AUROC) and the corrected partial AUROC at specificities ≥ 90% (pAUROC₉₀). Algorithmic bias was tested by comparing pAUROC₉₀ across each model between Black and White children.</p><p><strong>Data sources and analytic sample: </strong>The modeling dataset was comprised of Medicaid claims and patient demographics data from Partners For Kids, a pediatric accountable care organization.</p><p><strong>Principal findings: </strong>Overall, XGBoost models outperformed LASSO models. When race was included in the model, XGBoost had an AUROC of 0.78 (95% confidence interval [CI]: 0.77-0.79) while the LASSO model had an AUROC of 0.75 (95% CI: 0.74-0.77). When race was excluded from the model, XGBoost had an AUROC of 0.76 (95% CI: 0.74-0.77) while LASSO had an AUROC of 0.73 (95% CI: 0.72-0.74).</p><p><strong>Conclusions: </strong>The more complex XGBoost outperformed the simpler LASSO in predicting out-of-home placement and had less evidence of racial bias. This study highlights the complexities of developing predictive models in systems with known racial disparities and illustrates what can be accomplished when ML developers and policy leaders collaborate to maximize data to meet the needs of children and families.</p>","PeriodicalId":55065,"journal":{"name":"Health Services Research","volume":" ","pages":"e14601"},"PeriodicalIF":3.1,"publicationDate":"2025-03-06","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"143568882","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":"Examining Trends in Medicare Advantage Plan Disenrollment Associated With Expanded Supplemental Benefit Adoption.","authors":"Emma L Tucher, David J Meyers, Amal N Trivedi, Laura M Gottlieb, Kali S Thomas","doi":"10.1111/1475-6773.14460","DOIUrl":"https://doi.org/10.1111/1475-6773.14460","url":null,"abstract":"<p><strong>Objective: </strong>To evaluate the association between Medicare Advantage (MA) supplemental benefit adoption and plan disenrollment among plans that adopted either the 2019 nonmedical primarily health-related benefits (PHRB) or the 2020 social needs Special Supplemental Benefits for the Chronically Ill (SSBCIs).</p><p><strong>Study setting and design: </strong>We linked individual-level Medicare administrative data to publicly available, plan-level MA benefit, enrollment, crosswalk, and penetration files from 2017 to 2021. The PHRB benefits included benefits such as caregiver support, adult day care, in-home support services, and so forth. The SSBCI benefits included benefits such as food and produce, nonmedical transportation, pest control, and so forth. We used a difference-in-differences design studying MA enrollees stratified by Medicare-Medicaid dual eligibility status.</p><p><strong>Data sources and analytic sample: </strong>We included individuals from across the 50 United States and DC enrolled in MA plans that adopted a PHRB in 2019 or SSBCI in 2020 and matched comparator plans from the same counties that did not adopt either benefit. Individuals were excluded if they moved, died, or lacked county-level information during the year.</p><p><strong>Principal findings: </strong>Our sample includes 8,947,810 unique MA enrollees (27.4% in plans that adopted a PHRB and 1.0% in plans that adopted an SSBCI). For dual-eligible enrollees, neither PHRB adoption (0.2%, 95% CI, -2.7%, 2.8%) nor SSBCI adoption (-1.7%, 95% CI, -6.0%, 2.5%) was significantly associated with the rate of plan disenrollment. For Medicare-only enrollees, neither PHRB adoption (-2.6%, 95% CI, -5.9%, 0.7%) nor SSBCI adoption (-5.4%, 95% CI, -15.8%, 5.1%) was significantly associated with the disenrollment rate.</p><p><strong>Conclusion: </strong>The promise of these benefits was that MA plans could more directly address enrollees' nonmedical and social needs, leading to better social and health outcomes and reducing costs. We find that adoption did not decrease plan disenrollment, which suggests it may not drive enrollment decisions.</p>","PeriodicalId":55065,"journal":{"name":"Health Services Research","volume":" ","pages":"e14460"},"PeriodicalIF":3.1,"publicationDate":"2025-03-06","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"143568948","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":"Hospital and Skilled Nursing Facility Networks: Informal Relationships and Their Role in the Placement of Traditional Medicare Beneficiaries With Serious Mental Illness.","authors":"Taylor I Bucy, Donovan T Maust, Dori A Cross","doi":"10.1111/1475-6773.14465","DOIUrl":"https://doi.org/10.1111/1475-6773.14465","url":null,"abstract":"<p><strong>Objective: </strong>To examine the role of hospitals' high-volume preferred provider networks in skilled nursing facility (SNF) placement for traditional Medicare beneficiaries with serious mental illnesses (SMI).</p><p><strong>Study setting and design: </strong>We describe the differential effect of preferred provider networks on the location of observed SNF admission (i.e., placement) for patients with and without SMI using ordinary least squares (OLS) regression and conditional logistic regression. We also consider the moderating effect of having a co-occurring condition targeted by value-based payment programs.</p><p><strong>Data sources and analytic sample: </strong>A 100% sample of Medicare Provider Analysis and Review (MedPAR) files used to identify acute care hospital-to-SNF transitions between 2017 and 2019.</p><p><strong>Principal findings: </strong>Overall, patients with SMI have a lower probability of being admitted to a referring hospital's preferred SNF partner (48.0% vs. 52.4%; p < 0.001). We find evidence that incentives introduced through the hospital readmission reduction program (HRRP) moderate this observed relationship, where, relative to their SMI counterparts, individuals with SMI and an HRRP condition have a greater probability of being admitted to a preferred SNF (47.6% vs. 51.1%; p < 0.001). We find similar effects using conditional logistic regression, where preferredness is significantly more predictive of admission to the most proximate SNF for patients without SMI versus those with SMI. This effect is again moderated by the presence of a co-occurring HRRP condition.</p><p><strong>Conclusions: </strong>Volume-driven preferred partner relationships differentially impact referral patterns for traditional Medicare patients with SMI. Our findings suggest that patients with complex mental and behavioral health conditions may not benefit equally from more targeted investments in transitional care practices that are made in response to these partnerships. Yet our findings are also suggestive of opportunities to leverage existing hospital-SNF relational dynamics to improve the quality of care for a broader group of medically and socially complex patients.</p>","PeriodicalId":55065,"journal":{"name":"Health Services Research","volume":" ","pages":"e14465"},"PeriodicalIF":3.1,"publicationDate":"2025-03-04","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"143544553","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":"Disabled Patients' Experiences of Healthcare Services in a Nationally Representative Sample of U.S. Adults.","authors":"Elizabeth M Stone, Sofia Bonsignore, Stephen Crystal, Hillary Samples","doi":"10.1111/1475-6773.14598","DOIUrl":"https://doi.org/10.1111/1475-6773.14598","url":null,"abstract":"<p><strong>Objective: </strong>To examine patient-reported experiences of healthcare services by disability status.</p><p><strong>Study setting and design: </strong>We conducted a cross-sectional analysis of Consumer Assessment of Healthcare Providers and Systems (CAHPS) measures of overall healthcare satisfaction, timeliness of care, and patient-provider interactions to assess differences by disability status and, among those with a disability, between those with sensory, physical, cognitive, or multiple disabilities.</p><p><strong>Data sources and analytic sample: </strong>CAHPS measures included in the 2021 Medical Expenditure Panel Survey for U.S. adults.</p><p><strong>Principal findings: </strong>People with disabilities reported significantly lower ratings of healthcare services compared to the general population (7.98, 95% CI: 7.89-8.08 vs. 8.38, 95% CI: 8.34-8.43 on a scale of 0 [worst] to 10 [best]), with the lowest satisfaction among people with multiple disabilities (7.87, 95% CI: 7.72-8.02). Disabled people reported worse experiences on all measures compared to people without disabilities. People with physical, cognitive, and multiple disabilities reported significantly worse experiences of healthcare services than those with sensory disabilities.</p><p><strong>Conclusions: </strong>In a nationally representative sample of U.S. adults, disabled people reported lower satisfaction with healthcare services, less timely care, and worse provider interactions than people without disabilities. Changes to policy and practice are needed to improve healthcare experiences for disabled people.</p>","PeriodicalId":55065,"journal":{"name":"Health Services Research","volume":" ","pages":"e14598"},"PeriodicalIF":3.1,"publicationDate":"2025-03-04","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"143544552","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 Impact of Introducing Managed Care Intermediaries for Long-Term Services and Supports.","authors":"Deepon Bhaumik, Jacob Wallace, David C Grabowski, Mark J Schlesinger","doi":"10.1111/1475-6773.14462","DOIUrl":"https://doi.org/10.1111/1475-6773.14462","url":null,"abstract":"<p><strong>Objective: </strong>To study the impact of managed long-term services and supports (MLTSS) on the use of long-term care, as well as acute care.</p><p><strong>Study setting and design: </strong>We use a staggered difference-in-differences (DiDs) regression design, exploiting the variation in timing of the rollout of MLTSS programs across states between 2004 and 2018. We compared individuals in states that implemented MLTSS with individuals in states that did not implement MLTSS. Our outcomes included formal home care use, nursing home status, informal care use, hospitalizations, overnight nursing home visits, and falls.</p><p><strong>Data source and analytic sample: </strong>This study uses secondary data from the Health and Retirement Study data, linked with state identifiers. The sample includes adults aged 65 and older who report at least one functional limitation.</p><p><strong>Principal findings: </strong>The shift to MLTSS leads to a 2.5 percentage point (pp) increase (95% CI: 0.8 pp, 4.3 pp) in home care users, a 3-percentage point decrease (95% CI: -5.38 pp, -0.25 pp) in informal care users, and no statistically significant change in nursing home occupancy or health outcomes. We also find suggestive evidence of reductions in the number of home care individuals living in MLTSS states receive, with a 7.02-h (95% CI: -12.96, -1.07), or nearly 27% decrease, in monthly formal care received by this population.</p><p><strong>Conclusion: </strong>These findings suggest that MLTSS increased the share of home and community-based services (HCBS) users but restricted the amount of HCBS used per beneficiary, with ambiguity around whether this occurred at the expense of beneficiaries.</p>","PeriodicalId":55065,"journal":{"name":"Health Services Research","volume":" ","pages":"e14462"},"PeriodicalIF":3.1,"publicationDate":"2025-02-27","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"143525325","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}