Meredith B. Rosenthal

Objective: To examine whether out‐of‐pocket costs during pregnancy and delivery affect use of postpartum care. Study Setting and Design: Because health insurance deductibles and limits reset annually, the timing of childbirth within that year quasi‐randomly assigns people to different levels of cost‐sharing during pregnancy+delivery versus postpartum. We use a novel instrumental variable approach that leverages this variation to analyze whether higher maternity spending due to delivering early in the plan year affects postpartum care utilization. The exposure is maternity out‐of‐pocket spending, and the instrument is whether the delivery was in the first three versus last 3 months of the enrollee's health plan year; the primary outcome is use of any outpatient care postpartum. We analyze maternity episodes among Blue Cross Blue Shield of Massachusetts enrollees who gave birth, 2019–2023. Data Sources and Analytic Sample: Commercial health insurance enrollment and claims data for individuals with continuous enrollment during pregnancy, delivery, and 3‐months postpartum ( N = 51,337). Principal Findings: Out‐of‐pocket costs for those delivering at the start versus the end of their health plan year were, on average, 21% higher for pregnancy+delivery care and 58% lower for postpartum care. A $100 increase in pregnancy+delivery out‐of‐pocket spending led to a 0.53 percentage point (95% CI [0.28, 0.79]) increase in use of any outpatient postpartum care (sample mean: 82.5%). Higher pregnancy+delivery out‐of‐pocket costs also led to significant increases in the number of outpatient contact days, visits for preventive/well care, visits for mental health, and other visits. Conclusions: Higher pregnancy+delivery out‐of‐pocket costs due to delivering early in the plan year corresponded to lower postpartum out‐of‐pocket costs and led to modest increases in postpartum care. This suggests that lower postpartum cost‐sharing may increase postpartum care use. Policies that lower those costs may be effective in increasing use of postpartum care.

We examined the effects of ownership and contracting relationships between primary care physicians (PCPs) and large health systems on care utilization and cost in Massachusetts from 2017 to 2021. Thirty-nine percent of treated patient-years were associated with ownership relationships and 61.0% with contracting relationships. A patient’s PCP entering an ownership relationship increased the probability of admission to a within-system hospital by 0.75ppt (95% CI [0.54, 0.95]; p < .001) and to a top price hospital by 4.08ppt (95% CI [2.07, 6.08; p < .001); the effect of a contracting relationship was 0.52ppt (95% CI [0.39, 0.65]; p < . 001) and 2.98ppt (95% CI [1.26, 4.71]; p < .001), respectively. Ownership and contracting relationships increased the probability of outpatient follow-up with a within-system physician after hospitalization by 2.91ppt (95% CI [0.26, 5.56]; p = .032) and 2.61ppt (95% CI [0.57, 4.65]; p = .012), respectively. Our findings that both relationships exhibit similar effects suggest that policymaking and research on vertical consolidation may need to broaden beyond outright ownership.

Geronimo Bejarano, David J Meyers, Meredith B Rosenthal, Jeffrey Marr; Hospital-Medicare Advantage Vertical Integration and Medical Loss Ratios, Health Aff

Objective: To assess the impact of state legislation banning healthcare workers from using sexual orientation and gender identity change efforts with minors (attempts to convert sexual and gender diverse individuals to be heterosexual and/or cisgender; also known as “conversion therapies”) on adolescent suicidality.Study Setting and Design: We used high school student responses to the 2011–2019 Youth Risk Behavior Survey. Using a quasi‐experimental stacked difference‐in‐differences (DID) approach, we estimated the association between bans and rates of seriously considering suicide in the past year. In states that included sexual orientation survey questions, we assessed the association between bans and considering suicide for sexual minority and heterosexual youth.Data Sources and Analytic Sample: Retrospective analysis of 181,950 youth across four treatment states (Illinois, Connecticut, Rhode Island, and Maryland) and 240,268 youth across 25 control states. Treatment states included those that: (1) passed bans during the study period, (2) passed bans independent of antibullying and nondiscrimination laws, and (3) participated in the Youth Risk Behavior Survey for one wave before and one wave after passing a ban. For secondary analyses by sexual identity, 11 control states were available.Principal Findings: Among respondents, 17% reported seriously considering suicide in the prior year. In the 2 years following sexual orientation and gender identity change effort bans, rates of considering suicide were 2.9 percentage points lower (95% CI: −4.2, −1.6) in states with bans compared to control states. Improvements appeared to be larger for lesbian, gay, and bisexual youth (4.6 percentage point reduction; 95% CI: −6.4, −2.8) than for heterosexual youth. Reductions were statistically significant in Illinois, Connecticut, and Rhode Island compared to control states, but not in Maryland.Conclusions: State laws banning sexual orientation and gender identity change efforts by healthcare providers for minors were associated with reduced rates of considering suicide among high school students.

Enacted in 2010, the Patient Protection and Affordable Care Act (ACA) expanded health insurance to millions of people in the US.^1,2 Among other provisions, the ACA enabled state Medicaid programs to cover all low-income adults up to 138% of the federal poverty level.^1,3,4 Its dependent coverage mandate required private health insurance plans to allow adult children aged 19 to 25 years to stay on their parents’ plans.¹ It also introduced health insurance marketplaces, which expanded coverage to individuals without other health insurance.¹ Studies have found the ACA was associated with increased insurance coverage rates, improved health outcomes, increased political participation, and decreased medical debt for the general population.^5-8

Objective: To understand variation in enrollment in tiered network health plans (TNPs) and the local provider market characteristics associated with TNP penetration.Data Sources and Study Setting: We used 2013–2017 Massachusetts three‐digit ZIP code level employer‐sponsored health insurance enrollment data, data on physician horizontal and vertical affiliations from the Massachusetts Provider Database, state hospital reports in 2013, 2015, and 2017, and the 2013–2017 Massachusetts All‐Payer Claims database.Study Design: Linear regressions were used to estimate associations between TNP and local provider market characteristics.Data Extraction: We constructed measures of TNP penetration and local provider market characteristics and linked these data using three‐digit ZIP code.Principal Findings: TNP penetration was at least 10% in all employer market sectors and highest among jumbo sized employers. All state employee health plan enrollees were in a tiered network health plan. Among enrollees not in the state employee health plan, TNP penetration varied from 6.0% to 19.6% across three‐digit ZIP codes in Massachusetts. TNP penetration was higher in areas with less horizontal and vertical physician market concentration.Conclusions: Market competition, rather than the absolute quantity of physicians in an area, is associated with TNP penetration.

Alzheimer disease (AD), the most common form of dementia, affects more than 5 million US residents and progressively leads to a loss of memory and cognitive fun