Geoffrey J. Hoffman

The hospital wage index standardizes Medicare hospital payments for labor cost differences, paying otherwise equivalent hospitals more when they operate in areas with higher labor costs than in areas with lower labor costs. However, because of a plethora of exceptions, labor costs are commonly disconnected from the originally assigned wage index, and policy makers have expressed concerns that exceptions are not justified. Using publicly available wage index and Centers for Medicare and Medicaid Services impact files, we found that wage index exceptions increased by nearly 60 percent from 2016 to 2024 and were highly prevalent, with more than 70 percent of hospitals receiving exceptions by 2024 (compared with 46 percent in 2016). Growth was disproportionate across states and hospital types. Two exceptions-geographic reclassifications and rural floor adjustments-increased annual hospital revenues by an average of $650,000 and $930,000, respectively. Growth in costly exceptions distorts wage index accuracy and impedes the policy's intended goal of calibrating payments to actual labor costs.

Background: Specialty registered nurse(RN)certification signifies advanced clinical expertise, yet evidence linking certified RNs providing direct patient care to outcomes is lacking.Purpose: To examine the association between specialty RN certification and patient outcomes and the moderating effect of nurses’ formal education level.Methods: A retrospective observational study linked patient data to nurses providing their care across four hospitals (42,078 patients; 2,683 nurses). Mixed-effects regression models examined associations between specialty-certified RN care and outcomes, adjusting for patient and nurse characteristics.Findings: Twenty-seven percent of an average patient’s care was delivered by specialty-certified RNs. Greater exposure to specialty-certified-RN care was associated with lower odds of in-hospital mortality, pressure injury, urinary catheter-associated bacteriuria, and central line–associated bloodstream bacteremia, independent of BSN-or-higher–prepared RN care.Discussion: Specialty RN certification is associated with better patient outcomes. Organizations should prioritize supporting, incentivizing, and retaining specialty-certified RNs to improve patient outcomes and reduce the costs of preventable complications.

Importance: Since 2012, the Hospital Readmissions Reduction Program (HRRP) has penalized hospitals for excess, risk-adjusted 30 day readmissions among traditional Medicare (TM) beneficiaries. While risk adjustment may address observable differences in patient severity, it cannot account for unobservable differences. Medicare Advantage (MA) enrollment has continued to increase, and MA beneficiaries have been found to be both observably and unobservably healthier than their TM counterparts. Because relatively lower-severity patients are increasingly likely to enroll in MA, hospitals with higher MA penetration may have unobservably higher-severity TM patients, resulting in higher-than-estimated readmission risk and excessive HRRP penalties. Objective: To determine whether unobserved selection, as proxied by MA penetration, could be associated with distorted HRRP penalties and how associations may be moderated by peer grouping, which was incorporated into HRRP’s 2019 revision to penalty calculations. Design, Setting, and Participants: This retrospective cohort study included hospitals serving Medicare beneficiaries from fiscal years 2019 to 2022 for 6 HRRP-targeted conditions, including acute myocardial infarction, chronic obstructive pulmonary disease, heart failure, pneumonia, coronary artery bypass graft surgery, and elective primary total hip or knee arthroplasty. Data were analyzed from January 2024 to October 2025. Exposure: MA penetration at the hospital-year level. Main Outcomes and Measures: Excess readmission ratios (ERRs) and calculated HRRP penalties at the hospital-year level. To test whether HRRP penalties could have been distorted by unobserved selection, the association between the share of hospital admissions for MA patients (MA penetration) and excess readmission ratios (ERRs) for all patients was estimated, controlling for county-level variation and hospital-level covariates. The ERRs were rescaled by MA penetration to account for unobserved selection, and the rescaled ERRs were used to reestimate HRRP penalties under non–peer grouping and peer grouping paradigms. Results: This study included 3203 hospitals and 12 135 hospital-years. After adjusting for MA penetration, estimates indicated that hospitals in the first quintile of MA penetration would be penalized by a mean (SD) of $30 736 ($24 819.75) more, while hospitals in the fifth quintile would be penalized by a mean (SD) of approximately $26 915 ($42 017.23) less. Peer grouping does not mitigate these penalty distortions. Across hospitals, penalty redistributions would amount to $284 to $297 million annually. Conclusions and Relevance: The findings of this study suggest that including MA penetration explicitly in risk adjustment or in peer group definitions may dampen distortions from unobservable patient severity in HRRP penalty calculations.

Medicare Advantage (MA) is growing in popularity, but it is seeing substantial plan disenrollments among high-risk Medicare beneficiaries. Understanding and addressing factors associated with disenrollment are crucial for improving MA access and quality but are complicated by data issues, including the inability to adequately assess beneficiaries' perceptions of access and quality in MA. Using data from the 2015-20 restricted Medicare Current Beneficiary Survey with information on beneficiaries' perceptions of access, cost, and quality, plus MA contract star ratings and plan generosity data, we assessed factors associated with disenrolling from an MA plan. Enrollees' self-reported inability to access and receive high-quality care, more than perceived burdens of out-of-pocket costs, was associated with MA plan disenrollment, as was an objective measure of plan generosity. Difficulty accessing needed medical care was more strongly associated with MA-to-traditional Medicare exits than MA-to-MA plan switching. Dissatisfaction with access, cost, and quality was much more common for enrollees in poor health. These findings renew concerns about access to high-quality care for high-risk and other MA enrollees.

Background and Objectives: This study draws upon local coronavirus disease 2019 (COVID-19) mortality rates as a proxy for pandemic severity to determine if the COVID-19 pandemic disrupted long-term services and supports (LTSS) for adults with dementia, relative to adults with care needs unrelated to dementia. Research Design and Methods: We used the Health and Retirement Study to estimate associations between local COVID-19 mortality rates from March 2020 through April 2021 and LTSS outcomes (receiving paid and unpaid help, monthly hours of paid and unpaid help, number of paid and unpaid helpers, living in a residential care setting, or living with adult children). We compared 2 groups of adults ages 51 and older: those with dementia (n = 522) and those without dementia but having difficulty with at least one activity of daily living (n = 2,036). Results: We found that higher local COVID-19 mortality rates were associated with a reduction in paid care and living in residential care settings for both groups of adults with care needs. In addition, higher local COVID-19 mortality rates were associated with a greater likelihood of living with adult children among those without dementia and greater hours of unpaid help among those with dementia. Discussion and Implications: Although we did not find differences in disruptions of LTSS between persons with and without dementia, observed declines in paid LTSS and increases in unpaid care in the first year of the pandemic may nevertheless have different implications for persons with dementia. Future research should investigate if COVID-19 related disruptions in LTSS led to differential changes in health and unmet needs among adults with dementia, increased strain for their caregivers, and the equitable availability of high-quality paid care.

INTRODUCTION: While hospital‐related spending is substantially higher for ADRD populations, it is unknown whether differences exist in the use of hospital services in those hospitals serving high proportions of patients with dementia.METHODS: We used 2014–2019 Medicare claims to compare hospitals treating high (321 high dementia concentration hospitals [HDCH]) and low (2887 non‐HDCHs) proportions of dementia populations according to finances, utilization, and quality.RESULTS: More than one‐quarter of HDCH patients have dementia. HDCHs are small, treat minoritized patient populations, have low‐profit margins and poor overall performance, but are associated with lower 1‐month mortality risk for dementia populations.DISCUSSION: Large proportions of patients treated at a subset of small, poorly resourced, and poorly performing US hospitals have dementia. However, unlike at larger, better‐performing hospitals, those treated at HDCHs appear to have lower mortality risk. This may reflect the benefits of specialization or other benefits of treatment at smaller, community hospitals.

Objective: To determine whether rural hospital closures affected hospital and post‐acute care (PAC) use and outcomes.Study Setting and Design: Using a staggered difference‐in‐differences design, we evaluated associations between 32 rural hospital closures and changes in county‐level: (1) travel distances to and lengths of stay at hospitals; (2) functional limitations at and time from hospital discharge to start of PAC episode; (3) 30‐day readmissions and mortality and hospitalizations for a fall‐related injury; and (4) population‐level hospitalization and death rates.Data Sources and Analytic Sample: 100% Medicare claims and home health and skilled nursing facility clinical data to identify approximately 3 million discharges for older fee‐for‐service Medicare beneficiaries.Principal Findings: We found that hospitals that closed compared to those remaining open served more minoritized, lower‐income populations, including more Medicaid and fewer commercial patients, and had lower profit margins. Following a closure, quarterly hospitalization rates (111.6 quarterly hospitalizations per 10,000 older adults; 95% CI: 53.4, 170.9) and average hospital lengths of stay increased (0.34 days; 95% CI: 0.13, 0.56 days). We observed no change in the average distance between patients' residential ZIP code and the hospital used (0.29 miles; 95% CI: −1.06, 1.64 miles); average number of standardized ADL limitations at PAC (0.08 SDs from the pre‐closure average; 95% CI: −0.12, 0.28 SDs); or PAC time to start (0.02 days; 95% CI: −1.2, 1.2 days). Among more isolated hospitals, closures were associated with an increase in the likelihood of readmission (0.10 percentage‐points; 95% CI: 0.00, 0.19).Conclusions: Closures were not associated with notably worsened health care access, function, or health, potentially because closures triggered care delivery adjustments involving increased numbers of patients seeking out higher quality care.

Objective: To evaluate whether having previously disenrolled from Medicare Advantage (MA) is associated with lower hazards of future MA enrollment.Data Sources and Study Setting: Secondary data from Medicare.Study Design: We examined beneficiaries with baseline FFS enrollment from 2017–2019 using a 20% sample of Medicare claims. Cox proportional hazard models were used to examine the association of prior MA enrollment (in the three years prior to baseline FFS enrollment) with MA re‐enrollment, and whether this association is modified by Alzheimer's Disease and Related Dementias (ADRD), prior nursing home use, chronic illness, dual eligible status, and availability of MA plans and quality.Data Collection: Not applicable.Principal Findings: Overall, 3.3% of beneficiaries switched to MA annually. Of those with prior MA enrollment, MA switching percentages were 9.0%, 4.6%, and 6.8% for those whose most recent MA enrollments were 1, 2, and 3 years prior to their baseline FFS year. Comparatively, the switching percentages was 3.2% for those with no prior MA enrollment. The hazards of switching to MA were 2.73 (p < 0.001), 1.29 (p < 0.001), and 1.97 (p < 0.001) times greater than remaining in FFS for beneficiaries whose most recent MA enrollments were one, two, and three years prior to their baseline FFS year. Hazards of switching were generally similar between those with and without ADRD, stratified by recency in prior MA experience, except those with dual eligibility. Among those with ADRD, switching hazards were greatest for 3 years prior MA enrollees in counties with the fewest available (HR: 3.84, p < 0.001) and lowest‐rated plans (HR: 4.02, p < 0.001).Conclusions: Recency of switching from MA to FFS was the strongest predictor of a FFS‐to‐MA switch, identifying a population of beneficiaries who multiply switch regardless of health status or MA access. Future health policy considerations should more closely examine the vulnerabilities and long‐term outcomes of this population.