Jing Li

Background: Subscription-based payment models (SBPMs) have been adopted to expand access to hepatitis C virus (HCV) treatment within Medicaid programs. Objective: To evaluate the impact of SBPMs on HCV screening, RNA testing, and direct-acting antiviral (DAA) uptake among Medicaid Managed Care enrollees in Louisiana and Washington, and to identify factors associated with differential policy effects. Research Design: Quasi-experimental study using the synthetic control method to compare outcomes in Louisiana and Washington—the only states implementing SBPMs in July 2019—with weighted combinations of 14 control states. Subjects: Adults aged 18–64 years or older enrolled in Medicaid Managed Care between January 2018 and December 2022. Measures: Monthly HCV screening, RNA testing, DAA initiation, and refill rates identified from payer-complete closed claims. Results: Louisiana SBPM was associated with significant increases in RNA testing (+35.2/100,000 persons/mo), DAA initiation (+7.8/1000 patients/mo), and DAA refills (+24.4/1000 patients/mo; all P =0.07). Gains were broad-based across subgroups and geographically consistent. Washington SBPM was associated with nonsignificant screening changes and significant declines in DAA initiation (−3.6/1000 patients/mo) and refills (−12.9/1000 patients/mo; P =0.07), with uniformly negative or null subgroup effects. Conclusions: SBPM yielded markedly different outcomes across states. Louisiana gains likely reflect convergence with recent Medicaid expansion and prior removal of DAA restrictions, generating a large treatment-eligible pool at implementation. Washington earlier expansion (2014) and fibrosis-restriction removal (2016) may have already addressed this demand. As the federal government invests $12.3 billion in HCV elimination with SBPM as a central mechanism, payment reform must be paired with comprehensive strategies—including provider engagement, screening infrastructure, and patient navigation—to achieve elimination goals.

Financial incentives can distort physicians' treatment decisions and amplify healthcare spending. Altruism, a core element of medical professionalism, may counteract these distortions. We link experimentally elicited altruism from a sample of U.S. physicians to administrative data on industry transfers and drug prescribing. Non-altruistic physicians receive substantially higher annual payments (USD 1,932, or 190%) relative to their altruistic peers and increase prescribing of promoted drugs after payment, whereas altruistic physicians do not. Heterogeneity by altruism is largest in drug classes with high clinical substitutability, where prescribing is more discretionary. Our findings suggest that physician altruism moderates the influence of financial incentives in industry ties, limiting the scope for agency problems in prescribing.

Spending at end of life (EOL) accounts for a large and growing share of healthcare expenditures in the US, and often reflects aggressive care with questionable value for dying patients. Using a novel instrumental variables approach, we conduct the first study on the causal effect of Medicare reimbursement for advance care planning (ACP)—the process of discussing and recording patient preferences for goals of care—on outcomes near EOL for critically ill Medicare patients. We find that billed ACP services substantially increase hospice spending within a year, with corresponding increase in one-year mortality. However, among those who die, death is significantly less likely to occur in the hospital, and total and inpatient spending within the last 30 days of life fall significantly. The impacts of ACP services on EOL outcomes are magnified among patients with cognitive impairment and those with lower socioeconomic status. Our findings suggest that paying for ACP services can be promising in improving patients’ quality of life at EOL while lowering EOL spending, especially for patients most vulnerable to receiving aggressive EOL care.

Background: Despite the high burden of Alzheimer’s disease and other dementias among the Hispanic population worldwide, little is known about how dementia affects healthcare utilizations among this population outside of the US, in particular among those in the Caribbean region. Objective: This study examines healthcare utilization associated with Alzheimer’s disease and other dementias among older adults in the Caribbean as compared to the US. Methods: We conducted harmonized analyses of two population-based surveys, the 10/66 Dementia Group Research data collected in Dominican Republic, Cuba, and Puerto Rico, and the US-based Health and Retirement Study. We examined changes in hospital nights and physician visits in response to incident and ongoing dementias. Results: Incident dementia significantly increased the risk of hospitalization and number of hospital nights in both populations. Ongoing dementia increased the risk of hospitalization and hospital nights in the US, with imprecise estimates for the Caribbean. The number of physician visits was elevated in the US but not in the Caribbean. Conclusions: The concentration of increased healthcare utilization on hospital care and among patients with incident dementia suggests an opportunity for improved outpatient management of new and existing dementia patients in the Caribbean.

Objective: To construct a new measure of end‐of‐life (EoL) spending—the elevated EoL spending—and examine its associations with measures of quality of care and patient and physician preferences in comparison with the commonly used total Medicare EoL spending measures.Data Sources and Study Setting: Medicare claims data for a 20% random sample of Medicare fee‐for‐service (FFS) patients, from the health care quality data for 2015–2016, from the Hospital Compare and the Medicare Geographic Variation public use file, and survey data about patient and physician preferences.Study Design: We constructed the elevated EoL spending measure as the differential monthly spending between decedents and survivors with the same one‐year mortality risk, where the risk was predicted using machine learning models. We then examined the associations of the hospital referral region (HRR)‐level elevated EoL spending with various health care quality measures and with the survey‐elicited patient and provider preferences. We also examined analogous associations for monthly total EoL spending on decedents.Data Extraction Methods: Medicare FFS patients who were continuously enrolled in Medicare Parts A & B in 2015 and were alive as of January 1, 2016.Principal Findings: We found a large variation in the elevated EoL spending across HRRs in the United States. There was no evidence of an association between HRR‐level elevated EoL spending and established health care quality measures, including those specific to EoL care, whereas total EoL spending was positively associated with certain quality of care measures. We also found no evidence that elevated EoL spending was associated with patient preferences for EoL care. However, elevated EoL spending was positively and significantly associated with physician preferences for treatment intensity.Conclusions: Our findings suggested that elevated EoL spending captures different resource use from conventional measures of EoL spending and may be more valuable in identifying potentially wasteful spending.