Kathleen Carey

Introduction: Medicaid programs have increasingly adopted value-based payment models, such as Accountable Care Organizations (ACOs), to improve quality of care and contain costs. Some evidence suggests that Medicaid ACOs have improved outcomes, but little is known about impacts on costs, including for maternity care, which comprises a large portion of Medicaid spending. Methods: Leveraging a natural experiment in Massachusetts, we evaluated the effects of Medicaid ACOs on total cost of care across the prenatal, delivery, and postpartum periods, including cost subcategories. Using claims data on 150 879 Medicaid-covered live deliveries, we used a difference-in-differences approach to compare costs before (quarter [Q] 1 2016 through Q4 2017) vs after (Q2 2018 through Q1 2023) Medicaid ACO implementation, among Medicaid ACO vs non-ACO deliveries, controlling for patient characteristics. Results: Results showed that the Medicaid ACO was not associated with statistical change in total cost of care across the perinatal period. Analysis of cost subcomponents found that the Medicaid ACO was associated with a 5% increase in inpatient delivery costs ($747) and a 21% decrease in emergency department costs (−$69). Conclusion: Expanding Medicaid ACOs may be a mechanism for improving care quality without increasing costs.

Objective: To examine the relationship between mental health provider productivity, staffing levels, and suicide‐related events (SREs) among U.S. Veterans receiving care within the Veterans Health Administration (VHA), focusing on therapy and medication management providers. Data Sources/Setting: We analyzed administrative data from the Department of Defense and VHA (2014–2018), encompassing 109,376 Veterans who separated from active duty between 2010 and 2017. Design: A longitudinal design estimated the effects of facility‐level provider work rate and staffing on SREs, adjusting for patient and facility characteristics. An instrumental variables (IV) approach addressed potential endogeneity. Data Collection/Extraction Methods: Data were obtained from the VHA Corporate Data Warehouse and the VHA Survey of Enrollees. Principal Findings: A 1% increase in therapy provider work rate led to a 12.1% increase in SRE probability, regardless of staffing levels. Conversely, a 1% increase in staffing levels led to a 1.6% reduction in SREs, with the largest effect in low‐staffed facilities. For medication management providers, work rate had no overall impact on SREs, except in medium‐staffed facilities. A 1% increase in staffing levels for medication management providers led to a 1.7% reduction in SREs. Conclusions: Increased work rates, particularly in low‐staffed VHA facilities, may elevate suicide‐related risks. In contrast, staffing increases simultaneously improve access and reduce adverse outcomes. Where possible, policymakers should prioritize staffing growth over productivity gains to improve access to mental health clinics and ensure Veteran safety and care quality.

Introduction: Medicare Merit-based Incentive Payment System (MIPS), established by Centers for Medicare & Medicaid Services to transition Medicare reimbursement toward value-based care, has faced criticism for its administrative complexity and potential inequities affecting safety-net providers (SNPs). Methods: This study analyzed 5-year data (2018-2022) to evaluate the performance and financial outcomes of clinicians consistently participating in MIPS, focusing on disparities between SNPs and non-SNPs. Results: We found that safety-net specialists were 31% more likely than non–safety-net specialists to consistently receive positive payment adjustments and earned modestly higher average adjustment rates (0.35% points). However, despite this superior performance, safety-net specialists did not achieve greater cumulative financial rewards due to MIPS's percentage-based adjustment structure, which disadvantages clinicians with smaller billing volumes. Our analysis also showed that MIPS financial incentives were generally modest—ranging from $300 to $4000 over 5 years—far below the estimated $12 000 in annual administrative compliance costs per physician reported in prior research. Conclusion: To address these disparities and inefficiencies, policymakers should consider alternative models such as the American Medical Association's proposed Data-Driven Performance Payment System, which reduces administrative burden by simplifying the reporting process and ensures fairer financial rewards by uncoupling incentive payments from billing volume—thereby improving equity for safety-net clinicians.

Background: Numerous US patients seek the hospital emergency department (ED) for behavioral health care. Community Health Centers (CHCs) offer a potential channel for redirecting many to a more patient-centered, lower cost setting. Objective: The aim of this study was to identify unique market areas serviced by CHCs and to examine whether CHCs are effective in offsetting behavioral health ED visits. Research Design: We identified CHC-year specific service areas using patient origin zip codes. We then estimated random effects models applied to 42 federally qualified CHCs operating in New York State during 2013–2020. The dependent variables were numbers of ED mental health (substance use disorder) visits per capita in a CHC’s service area, drawn from HCUP State Emergency Department Databases. Key explanatory variables measured CHC number of mental health (substance use disorder) visits, number of unique mental health (substance use disorder) patients, and mental health (substance use disorder) intensity, obtained from the HRSA Uniform Data System. Results: Controlling for population, we observed small negative effects of CHC behavioral health integration in explaining ED behavioral health utilization. Measures of mental health utilization in CHCs were associated with 1.3%–9.3% fewer mental health emergency department visits per capita in Community Health Centers’ service areas. Measures of substance use disorder utilization in Community Health Centers were associated with 1.3%–3.0% fewer emergency department visits per capita. Conclusion: Results suggest that behavioral health integration in CHCs may reduce reliance on hospital EDs, but that policymakers explore more avenues for regional coordination strategies that align services between CHCs and local hospitals.

Objective: To investigate the relationship between physician–hospital integration within accountable care organizations (ACOs) and inpatient care utilization and expenditure.Data Sources: The primary data were Massachusetts All‐Payer Claims Database (2009–2013).Study Setting: Fifteen provider organizations that entered a commercial ACO contract with a major private payer in Massachusetts between 2009 and 2013.Study Design: Using an instrumental variable approach, the study compared inpatient care delivery between patients of ACOs demonstrating high versus low integration. We measured physician–hospital integration within ACOs by the proportion of primary care physicians in an ACO who billed for outpatient services with a place‐of‐service code indicating employment or practice ownership by a hospital. The study sample comprised non‐elderly adults who had continuous insurance coverage and were attributed to one of the 15 ACOs. Outcomes of interest included total medical expenditure during an episode of inpatient care, length of stay (LOS) of the index hospitalization, and 30‐day readmission. An inpatient episode was defined as 30, 45, and 60 days from the admission date.Data Collection/Extraction Methods: Not applicable.Principal Findings: The study examined 33,535 admissions from patients served by the 15 ACOs. Average medical expenditure within 30 days of admission was $24,601, within 45 days was $26,447, and within 60 days was $28,043. Average LOS was 3.5 days, and 5.4% of patients were readmitted within 30 days. Physician–hospital integration was associated with a 10.6% reduction in 30‐day expenditure (95% CI, −15.1% to −5.9%). Corresponding estimates for 45 and 60 days were − 9.7% (95%CI, −14.2% to −4.9%) and − 9.6% (95%CI, −14.3% to −4.7%). Integration was associated with a 15.7% decrease in LOS (95%CI, −22.6% to −8.2%) but unrelated to 30‐day readmission rate.Conclusions: Our instrumental variable analysis shows physician–hospital integration with ACOs was associated with reduced inpatient spending and LOS, with no evidence of elevated readmission rates.

Objectives: To examine whether community health centers (CHCs) are effective in offsetting mental health emergency department (ED) visits.Data Sources and Study Setting: The HRSA Uniform Data System and the HCUP State ED Databases for Florida patients during 2012–2019.Study Design: We identified CHC‐year‐specific service areas using patient origin zip codes. We then estimated panel data models for number of ED mental health visits per capita in a CHC's service area. Models measured CHC mental health utilization as number of visits, unique patients, and intensity (visits per patient).Principal Findings: CHC mental health utilization increased approximately 100% during 2012–2019. Increased CHC mental health provision was associated with small reductions in ED mental health utilization. An annual increase of 1000 CHC mental health care visits (5%) was associated with 0.44% fewer ED mental health care visits (p = 0.153), and an increase of 1000 CHC mental health care patients (15%) with 1.9% fewer ED mental health care visits (p = 0.123). An increase of 1 annual mental health visit per patient was associated with 16% fewer ED mental health care visits (p = 0.011).Conclusions: Results suggest that mental health provision in CHCs may reduce reliance on hospital EDs, albeit minimally. Policies that promote alignment of services between CHCs and local hospitals may accelerate this effect.

Objective: To investigate the relative progress of safety‐net hospitals (SNHs) under Medicare's Comprehensive Care for Joint Replacement (CJR) mandatory bundled payment model over 2016–2020 and to identify the contributors to SNHs’ realization of success under the program.Data Sources/Study Setting: Secondary data on all CJR hospitals were collected from the Centers for Medicare and Medicaid Services (CMS) public use files and from the American Hospital Association.Study Design: We addressed whether SNHs can achieve progress in financial performance under CJR by focusing on the relative change in reconciliation payments or the difference between episode spending and target prices. We applied the method of dominance analysis to ordinary least squares regression to determine the relative importance of predictors of change in reconciliation payments over time.Principal Findings: Compared to CJR hospitals overall, SNHs were less successful in meeting episode spending targets. Hospital factors dominated socioeconomic factors in explaining progress among SNHs, but not among non‐SNHs. The contribution of nurse staffing was negligible across all CJR hospitals.Conclusions: The formula used by CMS to determine spending targets may not be sufficient to address disparities in SNH financial performance under mandatory bundled payment.

In recent years, commercial insurers have been slowly advancing coverage for telemedicine, raising questions regarding payment. Many states now have laws that address telemedicine reimbursement and as of 2019, 10 required full payment parity. Using a large commercial insurance claims database, this study conducted two natural experiments to better understand whether payment parity is effective in driving more telemedicine provision. Payments for common outpatient procedures provided by telemedicine and in offices during 2018–2019 were examined according to whether the service was subject to payment parity. For medical visits, evidence of payment incentives in promoting telemedicine was limited, and for psychotherapy telemedicine payments were comparable or greater than office visit payments. As telemedicine escalated during the COVID-19 peak and continues to grow beyond the pandemic, a valuable message is that payment parity laws may be a less effective strategy for encouraging telemedicine use than presumed by many state policymakers.

Background: Quantifying health care quality has long presented a challenge to identifying the relationship between provider level quality and cost. However, growing focus on quality improvement has led to greater interest in organizational performance, prompting payers to collect various indicators of quality that can be combined at the provider level. Objective: To explore the relationship between quality and average cost of medical visits provided in US Community Health Centers (CHCs) using composite measures of quality. Research Design: Using the Uniform Data System collected by the Bureau of Primary Care, we constructed composite measures by combining 9 process and 2 outcome indicators of primary care quality provided in 1331 US CHCs during 2015–2018. We explored different weighting schemes and different combinations of individual quality indicators constructed at the intermediate domain levels of chronic condition control, screening, and medication management. We used generalized linear modeling to regress average cost of a medical visit on composite quality measures, controlling for patient and health center factors. We examined the sensitivity of results to different weighting schemes and to combining individual quality indicators at the overall level compared with the intermediate domain level. Results: Both overall and domain level composites performed well in the estimations. Average cost of a medical visit was negatively associated with quality, although the magnitude of the effect varied across weighting schemes. Conclusion: Efforts toward improvement of primary health care quality delivered in CHCs need not involve greater cost.

Background: Telehealth services historically have played a small role in the provision of health care in the United States. However during the coronavirus disease 2019 (COVID-19) pandemic, public and private insurers rapidly expanded access to telehealth in order to reduce exposure and avoid transmission. It is unknown whether telehealth will become a more regular substitute for in-person care beyond the pandemic. Objective: Our objective was to provide evidence on the value of telehealth by comparing the productivity of physicians and other specialized clinicians who provide telehealth with the productivity of those who do not. Research Design: We conducted a retrospective data analysis of 17,705 unique providers in the areas of internal medicine, cardiology, dermatology, psychiatry, psychology, and optometry practicing in the US veterans affairs health care system during the period 2015 to 2018. For each year, we measured individual providers productivity by the total number of relative value units (RVUs) per full-time equivalent (FTE). We estimated the impact of providing telehealth on RVUs/FTE using fixed effects regression models estimated on a panel dataset of 58,873 provider-year observations and controlling for provider and patient characteristics. Results: Overall provider productivity increased in veterans affairs over the period, particularly in cardiology and dermatology. Providers of telehealth had above average productivity by 124 RVUs/FTE, or ∼4% of average total provider productivity. For the highest quartile of telehealth providers, average productivity was 188 RVUs/FTE higher than productivity of other providers. Conclusion: Strategies that encourage long-term integration of telehealth into provider practices may contribute to overall health care value.