Health affairs scholar最新文献_第3页

Streamlining oversight in Medicare advantage: measuring coding intensity via contract rankings. 简化医疗保险优势的监管：通过合同排名衡量编码强度。

IF 4.1

Health affairs scholar Pub Date : 2026-09-11 eCollection Date: 2026-09-01 DOI: 10.1093/haschl/qxag209

Trenton Chang, Michelle Qiu, Zhiyi Hu, Dylan Zapzalka, Divya M Shanmugam, Daniel K Shenfeld, Ravi B Parikh, Maggie Makar, Ezekiel J Emanuel, Zach Brown, Amanda E Kowalski, Jenna Wiens

{"title":"Streamlining oversight in Medicare advantage: measuring coding intensity via contract rankings.","authors":"Trenton Chang, Michelle Qiu, Zhiyi Hu, Dylan Zapzalka, Divya M Shanmugam, Daniel K Shenfeld, Ravi B Parikh, Maggie Makar, Ezekiel J Emanuel, Zach Brown, Amanda E Kowalski, Jenna Wiens","doi":"10.1093/haschl/qxag209","DOIUrl":"10.1093/haschl/qxag209","url":null,"abstract":"Introduction: Risk-adjusted payments in Medicare Advantage (MA) incentivize insurers to maximize reported diagnoses, resulting in high coding intensity, a major source of Medicare overpayments. However, distinguishing justifiable coding intensity from misreporting is challenging: some approaches risk conflating coding intensity due to extraneous diagnoses with that due to variation in clinical practice or beneficiary health, while others assume specific overreporting mechanisms.Methods: We propose a data-driven method for ranking MA contracts by coding intensity using comparisons between geographically co-located contracts based on adjusted diagnosis rates among switchers from Traditional Medicare to MA. The approach is applied to a 20% sample of 2019 MA claims.Results: Health Maintenance Organization (HMO)-dominated contracts tend to rank higher than preferred provider option (PPO)-dominated contracts, echoing previous findings. Furthermore, highly ranked contracts administer procedures and prescriptions relevant to beneficiaries' diagnoses less often than lower-ranked contracts, supporting the validity of the ranking. A simulation study suggests even an imperfect ranking can recover overpayments faster than a random audit, if mean diagnosis rates are low (10%) and vary widely across contracts.Conclusion: As MA looks to expand auditing strategies, MA enrollment continues to grow. The proposed approach can facilitate payer-specific audits even as mechanisms driving coding intensity evolve.","PeriodicalId":94025,"journal":{"name":"Health affairs scholar","volume":"4 9","pages":"qxag209"},"PeriodicalIF":4.1,"publicationDate":"2026-09-11","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC13564226/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"148956843","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

引用次数: 0

Three facts about private equity in the US hospital sector. 关于美国医疗行业私人股本的三个事实。

IF 4.1

Health affairs scholar Pub Date : 2026-09-10 eCollection Date: 2026-09-01 DOI: 10.1093/haschl/qxag217

Mark Naslund, Sungil Kim, Ambar La Forgia, Riley League, Ryan C McDevitt, Xingzhi Wang, Kelly Kaili Yang

{"title":"Three facts about private equity in the US hospital sector.","authors":"Mark Naslund, Sungil Kim, Ambar La Forgia, Riley League, Ryan C McDevitt, Xingzhi Wang, Kelly Kaili Yang","doi":"10.1093/haschl/qxag217","DOIUrl":"10.1093/haschl/qxag217","url":null,"abstract":"Introduction: Private equity (PE) ownership of US hospitals has grown over the past 25 years, attracting substantial academic and policy attention. Despite this interest, fragmented and incomplete transaction data have made it difficult to establish basic facts critical to an informed debate about PE's effects on hospitals, patients, and payers.Methods: Using a harmonized, publicly available PE acquisition data set, supplemented with verified exit transactions, we identify PE ownership spells for all short-term acute care hospitals from 2000 to 2024.Results: We identify 3 key facts: (1) PE ownership has never exceeded 7% of short-term acute care hospitals and was below 4% in 2024; (2) most PE firms exit within 5 years, typically through a sale to another PE firm or strategic acquirer, with bankruptcy and closure representing a small share; and (3) most Americans live in hospital referral regions that have no PE-owned hospitals.Conclusion: These findings indicate that PE ownership continues to represent a small share of hospitals.","PeriodicalId":94025,"journal":{"name":"Health affairs scholar","volume":"4 9","pages":"qxag217"},"PeriodicalIF":4.1,"publicationDate":"2026-09-10","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC13614267/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"149066811","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

引用次数: 0

Provider-sponsored insurers, medical loss ratios, and quality ratings in ACA marketplaces. 提供者赞助的保险公司，医疗损失率，以及ACA市场的质量评级。

IF 4.1

Health affairs scholar Pub Date : 2026-09-10 eCollection Date: 2026-10-01 DOI: 10.1093/haschl/qxag246

Lynn M Hua, Hyein Cho

{"title":"Provider-sponsored insurers, medical loss ratios, and quality ratings in ACA marketplaces.","authors":"Lynn M Hua, Hyein Cho","doi":"10.1093/haschl/qxag246","DOIUrl":"https://doi.org/10.1093/haschl/qxag246","url":null,"abstract":"Introduction: The Affordable Care Act's (ACA) medical loss ratio (MLR) regulation requires individual market insurers to spend at least 80% of premium revenue on medical care and quality improvement, but evidence is limited on whether MLRs correspond to measured quality and how this differs by insurer organizational structure.Methods: Using CMS MLR financial reports for ACA marketplace insurers (2015-2023) linked to Quality Rating System ratings (2020-2023), we compared provider-sponsored insurers owned by or operating as part of integrated delivery systems with traditional insurers on MLRs, spending components, and quality, using adjusted regressions.Results: Among 2751 issuer-state-years, 581 (21.1%) were provider-sponsored. Provider-sponsored insurers had MLRs 5.8 percentage points higher than traditional insurers (95% CI, 2.0 to 9.7). Provider-sponsored insurers had higher overall quality ratings (0.65 stars; 95% CI, 0.36 to 0.94), despite reporting $5.5 lower quality improvement expenses per member per month (95% CI, -8.9 to -2.2). A 10 percentage point higher MLR was associated with 0.15 higher stars (95% CI, 0.09 to 0.21). Prior-year, but not current-year, quality improvement expenses were associated with higher subsequent ratings (0.04 stars per $10 per member per month; 95% CI, 0.02 to 0.07).Conclusion: Organizational structure may shape MLR interpretation; direct quality measures may complement MLR regulation.","PeriodicalId":94025,"journal":{"name":"Health affairs scholar","volume":"4 10","pages":"qxag246"},"PeriodicalIF":4.1,"publicationDate":"2026-09-10","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC13637040/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"149120525","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

引用次数: 0

What's old is new: how anti-trans policy mimics the anti-abortion strategy that culminated in Dobbs. 旧的是新的：反变性政策是如何模仿在多布斯案中达到高潮的反堕胎策略的。

IF 4.1

Health affairs scholar Pub Date : 2026-09-10 eCollection Date: 2026-09-01 DOI: 10.1093/haschl/qxag249

Fiona R Miller, Gray Babbs, Elizabeth Tobin-Tyler, Benjamin P Brown

{"title":"What's old is new: how anti-trans policy mimics the anti-abortion strategy that culminated in Dobbs.","authors":"Fiona R Miller, Gray Babbs, Elizabeth Tobin-Tyler, Benjamin P Brown","doi":"10.1093/haschl/qxag249","DOIUrl":"10.1093/haschl/qxag249","url":null,"abstract":"Legislation restricting the rights of transgender people has increased dramatically in recent years. This trend echoes the historical arc of anti-abortion legislation. Over the 50 years between the US Supreme Court decisions in Roe and Dobbs, anti-abortion advocates worked to erode abortion access by expanding both the volume and scope of legislative attacks. While many of the bills proposed prior to Dobbs were enjoined pending litigation, their overall effect was to chill the provision of care, and propel a federal legal strategy that dismantled abortion access, paving the way for contemporary abortion bans. The anti-trans movement has followed the same playbook. In considering how to resist these assaults, the pro-abortion movement provides valuable lessons, both through an analysis of its strategic defeats, and of its post-Dobbs resilience. Advocates for trans rights must vigorously affirm the humanity of trans people, mobilize institutional support, and coordinate a strategic states-based defense to resist contemporary anti-trans legislation.","PeriodicalId":94025,"journal":{"name":"Health affairs scholar","volume":"4 9","pages":"qxag249"},"PeriodicalIF":4.1,"publicationDate":"2026-09-10","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC13587244/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"149009566","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

引用次数: 0

Sociodemographic characteristics of nurses entering and leaving the US nursing workforce in 2018 and 2022. 2018年和2022年进入和离开美国护理队伍的护士的社会人口特征。

IF 4.1

Health affairs scholar Pub Date : 2026-09-10 eCollection Date: 2026-09-01 DOI: 10.1093/haschl/qxag248

Kyla F Woodward, Sue Skillman, Bianca K Frogner

{"title":"Sociodemographic characteristics of nurses entering and leaving the US nursing workforce in 2018 and 2022.","authors":"Kyla F Woodward, Sue Skillman, Bianca K Frogner","doi":"10.1093/haschl/qxag248","DOIUrl":"https://doi.org/10.1093/haschl/qxag248","url":null,"abstract":"Introduction: Registered nurse (RN) workforce planning relies on a robust understanding of trends in nursing job dynamics. Relevant, current data on RNs' education, training, and job outcomes are critical to implementing solutions to mitigate high job vacancy rates or workforce shortages.Methods: This study used data from the 2018 and 2022 National Sample Survey of Registered Nurses to describe the sociodemographic characteristics and job dynamics of the nursing workforce before and after the pandemic, including nurses entering and leaving the workforce, and examined factors associated with leaving a primary job.Results: Despite concerns about 2018 weights, results suggest signs of increasing representation of Black RNs and potential declines in representation of Hispanic RNs over time respective to the US population. We found high rates of job turnover related to well-being and safety in the workplace in 2022.Conclusion: These findings suggest that strategies to increase workforce diversity have been successful among select groups, and ongoing policy should continue to focus on groups that are underrepresented. While the future of federal workforce diversity programs is unclear, states and organizations can implement strategies to support recruitment and retention of diverse groups of RNs.","PeriodicalId":94025,"journal":{"name":"Health affairs scholar","volume":"4 9","pages":"qxag248"},"PeriodicalIF":4.1,"publicationDate":"2026-09-10","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC13655441/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"149187033","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

引用次数: 0

Rebuilding health and human services: a call to strategic planning and action. 重建卫生和人类服务：呼吁进行战略规划和采取行动。

IF 4.1

Health affairs scholar Pub Date : 2026-09-09 eCollection Date: 2026-09-01 DOI: 10.1093/haschl/qxag245

Sean Bruna, Adam Sarvana

{"title":"Rebuilding health and human services: a call to strategic planning and action.","authors":"Sean Bruna, Adam Sarvana","doi":"10.1093/haschl/qxag245","DOIUrl":"10.1093/haschl/qxag245","url":null,"abstract":"The capacity of the U.S. Department of Health and Human Services (HHS) has been substantially reduced since early 2025. This has included staffing cuts on a scale not seen in decades, delays in implementing billions of dollars in grants, and other disruptions to normal operations, all of which have received considerable public coverage and attention. To date, far less public attention has been given to rebuilding efforts. This commentary presents recommendations for rebuilding HHS' lost capacity, following a series of roundtable discussions convened by a network of former senior HHS appointees. The roundtables included former HHS political appointees, career program staff and division leaders, and health policy researchers from universities, think tanks, and policy organizations. Based on common themes in these discussions, we propose 5 recommendations to rebuild HHS capacity: (1) treating and funding the rebuilding of federal health and health research capacity as an urgent national security priority; (2) shifting from reactive crisis management to coordinated forward planning; (3) continued documentation of what capacity has been lost and why; (4) establishing an independent, nonpartisan science advisory body across HHS; and (5) drafting legislation now so that policy windows are not missed when they open.","PeriodicalId":94025,"journal":{"name":"Health affairs scholar","volume":"4 9","pages":"qxag245"},"PeriodicalIF":4.1,"publicationDate":"2026-09-09","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC13602421/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"149042990","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

引用次数: 0

State-level paid sick leave: impacts of policy design on access by immigrant workers. 国家级带薪病假：政策设计对移民工人获得的影响。

IF 4.1

Health affairs scholar Pub Date : 2026-09-09 eCollection Date: 2026-09-01 DOI: 10.1093/haschl/qxag232

Zhenyi Luo, Aleta Sprague, Michael McCormack, Jody Heymann

{"title":"State-level paid sick leave: impacts of policy design on access by immigrant workers.","authors":"Zhenyi Luo, Aleta Sprague, Michael McCormack, Jody Heymann","doi":"10.1093/haschl/qxag232","DOIUrl":"10.1093/haschl/qxag232","url":null,"abstract":"Introduction: Access to paid sick days (PSDs) matters deeply to public health and workers' economic security. State-level PSD laws have expanded rapidly, yet little is known about whether they are closing coverage gaps for immigrant workers, who are both overrepresented in public-facing jobs and disproportionately excluded from employer-provided PSD.Methods: We built a state-level database of eligibility rules in all 15 states and DC with statewide PSD laws in effect as of 2024 and linked them to labor force data from the 2024 Current Population Survey Annual Social and Economic Supplement. We assessed how exclusions based on independent contractor status, firm size, minimum weekly hours, and annual work requirements shaped PSD coverage differences between citizens and noncitizens.Results: Overall, coverage was lower among noncitizens than citizens (84.0% vs 86.9%, P < .05). Significant disparities were identified in 6 jurisdictions, with the largest gap in Connecticut (49.3% vs 65.8%). Policy simulations showed that excluding independent contractors and small-firm employees were primary drivers of disparities. Removing these exclusions narrowed gaps and sometimes resulted in near-universal coverage.Conclusion: Removing exclusions from state-level PSD policies would reduce inequities and increase access for immigrant workers, with benefits for all.","PeriodicalId":94025,"journal":{"name":"Health affairs scholar","volume":"4 9","pages":"qxag232"},"PeriodicalIF":4.1,"publicationDate":"2026-09-09","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC13591275/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"149019238","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

引用次数: 0

Precision nutrition testing is the future of personalized care: evidence and coverage policies for equitable access. 精准营养检测是个性化护理的未来：公平获取的证据和覆盖政策。

IF 4.1

Health affairs scholar Pub Date : 2026-09-07 eCollection Date: 2026-09-01 DOI: 10.1093/haschl/qxag247

Danea M Horn, Hilary Seligman, Kathryn A Phillips

{"title":"Precision nutrition testing is the future of personalized care: evidence and coverage policies for equitable access.","authors":"Danea M Horn, Hilary Seligman, Kathryn A Phillips","doi":"10.1093/haschl/qxag247","DOIUrl":"10.1093/haschl/qxag247","url":null,"abstract":"The one-size-fits-all approach to dietary and metabolic interventions often fails to improve population health outcomes. This problem has been made more urgent by the rise of GLP-1 receptor agonist medications for obesity, which are high-cost but have variable patient outcomes. Precision nutrition (PN) testing has the potential to address this gap by using biomarkers, such as genetics and metabolic profiles, to predict individual responses to foods and drug therapies. Although some PN tests are on the market, most are not FDA-approved or covered by insurers, requiring out-of-pocket payment and creating access disparities. In this Commentary, we draw on experience from precision medicine to argue that payers, developers, regulators, and professional societies must begin building the evidence and coverage infrastructure for PN testing now. Payer coverage will require demonstrated clinical utility and defined clinical pathways that guide who should be tested and how results should change care. The policy question is not whether current tests should be covered; they should not be broadly covered without evidence, but whether the health system is preparing for equitable implementation once validated tests emerge. Building evidence and coverage infrastructure proactively will help ensure that future PN testing innovations improve population health equitably rather than widen existing disparities.","PeriodicalId":94025,"journal":{"name":"Health affairs scholar","volume":"4 9","pages":"qxag247"},"PeriodicalIF":4.1,"publicationDate":"2026-09-07","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC13614476/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"149066789","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

引用次数: 0

The vendorification of Medicare Advantage. 医疗保险优势的认可。

IF 4.1

Health affairs scholar Pub Date : 2026-09-05 eCollection Date: 2026-09-01 DOI: 10.1093/haschl/qxag243

David J Meyers, Jeffrey Marr

引用次数: 0

Does Medicare Advantage funding disparity affect managed care insurers' profitability? Evidence from Puerto Rico. 医疗保险优势资金差距是否影响管理式医疗保险公司的盈利能力？波多黎各的证据。

IF 4.1

Health affairs scholar Pub Date : 2026-09-04 eCollection Date: 2026-09-01 DOI: 10.1093/haschl/qxag242

Sergio A Rivera-Rodríguez, Naomi Zewde, Alexandra C Rivera-González

{"title":"Does Medicare Advantage funding disparity affect managed care insurers' profitability? Evidence from Puerto Rico.","authors":"Sergio A Rivera-Rodríguez, Naomi Zewde, Alexandra C Rivera-González","doi":"10.1093/haschl/qxag242","DOIUrl":"10.1093/haschl/qxag242","url":null,"abstract":"Introduction: Puerto Rico's Medicare Advantage market operates under a persistent yet fluctuating federal funding disparity, with reported benchmark payments approximately 38% below those in US states. Health insurance industry representatives have argued that this disparity constrains their financial margins, warranting measures to reduce healthcare benefits and demand more federal funds for Medicare.Methods: This study assessed the relationship between Puerto Rico's Medicare funding disparity and medical loss ratio, administrative loss ratio, and profit margins within the Medicare Advantage market. We analyzed insurer financial statements filed with the Puerto Rico Insurance Commissioner Office and Part C plan payment data from the Centers for Medicare & Medicaid Services using descriptive trends and regression models.Results: The funding disparity was not significantly associated with medical loss ratio or profit margin, but was associated with higher administrative loss ratio. Profit margins exhibit abrupt fluctuations coinciding with external shocks affecting healthcare utilization and the healthcare market.Conclusion: Annual variation in the funding disparity alone does not explain insurer financial performance. Efforts to increase federal Medicare Advantage payments to Puerto Rico should be accompanied by oversight regarding how additional revenues are allocated among medical care, administrative activities, and profits.","PeriodicalId":94025,"journal":{"name":"Health affairs scholar","volume":"4 9","pages":"qxag242"},"PeriodicalIF":4.1,"publicationDate":"2026-09-04","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC13587251/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"149009628","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

引用次数: 0