Amber K. Sabbatini

Expert consensus recommendations from 21 academic centers were established for appropriate radiography utilization at 12 potentially low-yield anatomic sites through a multidisciplinary process endorsed by six major American medical societies.

Background: Tele‐behavioral health (TBH) expanded significantly during the COVID‐19 pandemic, but the extent to which this addressed or reinforced existing rural–urban disparities remains unclear, especially in states with diverse and underserved populations. This study investigates the role of rurality and broadband access in TBH utilization among adult Medicaid beneficiaries in New Mexico—a highly rural and racially diverse state. Methods: We analyzed New Mexico Medicaid claims data from March 2019 to March 2021 for outpatient behavioral health visits. Using logistic regression models, we assessed differences in TBH use by rurality, race/ethnicity, and broadband connectivity across pre‐ and post‐public health emergency (PHE) periods. Visits were categorized by modality (in‐person, audio‐only, video) and linked with county‐level data on broadband access and provider availability. Results: Our study included 2,934,451 behavioral health visits among 216,898 unique Medicaid members. Total patient visits for BH increased by 19.2% from 1,326,473 (72.7% urban, 27.3% rural) to 1,607,978 (72.3% urban, 27.7% rural) across the study period. Urban patients had greater odds of TBH use (specifically audio‐only visits) compared to rural patients, even in rural counties with high broadband access. Modeling results demonstrated that urban patients had greater odds of a TBH visit as compared to rural patients, which was more pronounced in high versus low connectivity counties (OR 2.20; 95% CI 2.21, 2.27 vs. OR 1.53; 95% CI 1.51, 1.56). Native American patients had the greatest odds of TBH visits, which may reflect established telehealth infrastructure within the Indian Health Service. Conclusions: TBH expanded behavioral health access for Medicaid beneficiaries, but rural disparities persist and are not mitigated by broadband access alone. Rather, existing telehealth infrastructure appears to be related to improved rural TBH access. These findings underscore the need for policy efforts beyond broadband expansion to achieve equitable TBH access across diverse and rural populations.

Hospital accountable care organization (ACO) participation did not impact emergency department admission rates, length of stay, or costs, suggesting limited effectiveness in reducing spending for unplanned admissions and challenging hospital-led ACO cost-saving strategies.

Objectives: Hospital participation in accountable care organizations (ACOs)—Medicare’s signature alternative payment model—continues to grow despite mixed evidence on spending and quality. This study examines whether hospital ACO participation is associated with changes in emergency department (ED) admission practices, hospital length of stay (LOS), and spending for unplanned admissions. Study Design: A difference-in-differences analysis of Medicare fee-for-service ED visits and hospitalizations (2008-2019). Methods: Medicare claims were linked to ACO tracking data from Torch Insight to identify hospitals that joined an ACO between 2012 and 2017 (6 cohorts, followed for a maximum of 5 years), the start date of their initial contract, and ACO characteristics. Key outcomes included ED admission and observation stay rates, hospital LOS for emergent admissions, and total costs for an index ED event. Results: Among the 995 hospitals (27.6% of the short-term hospitals in our study) that joined a Medicare ACO during the study period, program participation up to 5 years was not associated with changes in the rate of hospitalization from the ED, hospital LOS, or total costs of the index event. Findings remained consistent across ACO program, contract risk levels, year of program entry, and overall ACO performance (eg, whether the ACO generated shared savings). Conclusions: Hospitals did not significantly alter care delivery for unplanned hospitalizations after joining an ACO. These findings suggest that hospital-led ACOs may have limited impact on reducing costs for emergent admissions, raising concerns about their ability to drive meaningful care transformation.

Introduction A disproportionate share of Federally Qualified Health Center (FQHC) users have a behavioral health condition, but there exists limited research examining changes in behavioral health provision in FQHCs. The objectives of this study were to describe how the provision of behavioral health services by FQHCs to the population of people with behavioral health conditions has changed over time in the US, how these trends varied across states, and whether the proportion of total delivered services that are behavioral health services has changed within FQHCs over time. Methods Descriptive analysis using the Uniform Data System and Global Burden of Disease Datasets from years 2012 to 2019. Results From 2012 to 2019, FQHC behavioral health visits per 1,000 population with any behavioral health condition grew 103%, with a 26-fold difference in average rates across states during the study period. Annual behavioral health visits per patient increased from 3.2 to 2012 to 3.4 in 2019. From 2012 to 2019, the number of behavioral health visits per 1,000 FQHC patients grew by 51%, whereas the rate of asthma visits declined by 14%, heart disease visits declined by 4%, and hypertension and diabetes related visits remained stable (changing < 1% for both). Discussion/Conclusion Behavioral health visit growth at FQHCs outpaced national prevalence of behavioral health conditions. This growth was driven by FQHCs serving an increasing number of patients with behavioral health conditions, without sacrificing the frequency of visits for individual patients with behavioral health conditions.

Objective: To determine the extent to which counting observation stays changes hospital performance on 30-day readmission measures. Methods: This was a retrospective study of inpatient admissions and observation stays among fee-for-service Medicare enrollees in 2017. We generated 3 specifications of 30-day risk-standardized readmissions measures: the hospital-wide readmission (HWR) measure utilized by the Centers for Medicare and Medicaid Services, which captures inpatient readmissions within 30 days of inpatient discharge; an expanded HWR measure, which captures any unplanned hospitalization (inpatient admission or observation stay) within 30 days of inpatient discharge; an all-hospitalization readmission (AHR) measure, which captures any unplanned hospitalization following any hospital discharge (observation stays are included in both the numerator and denominator of the measure). Estimated excess readmissions for hospitals were compared across the 3 measures. High performers were defined as those with a lower-than-expected number of readmissions whereas low performers had higher-than-expected or excess readmissions. Multivariable logistic regression identified hospital characteristics associated with worse performance under the measures that included observation stays. Results: Our sample had 2586 hospitals with 5,749,779 hospitalizations. Observation stays ranged from 0% to 41.7% of total hospitalizations. Mean (SD) readmission rates were 16.6% (5.4) for the HWR, 18.5% (5.7) for the expanded HWR, and 17.9% (5.7) in the all-hospitalization readmission measure. Approximately 1 in 7 hospitals (14.9%) would switch from being classified as a high performer to a low performer or vice-versa if observation stays were fully included in the calculation of readmission rates. Safety-net hospitals and those with a higher propensity to use observation would perform significantly worse. Conclusions: Fully incorporating observation stays in readmission measures would substantially change performance in value-based programs for safety-net hospitals and hospitals with high rates of observation stays.

Objective: To evaluate whether Medicare's Hospital Readmissions Reduction Program (HRRP) is associated with increased observation stay use.Data Sources and Study Setting: A nationally representative sample of fee‐for‐service Medicare claims, January 2009–September 2016.Study Design: Using a difference‐in‐difference (DID) design, we modeled changes in observation stays as a proportion of total hospitalizations, separately comparing the initial (acute myocardial infarction, pneumonia, heart failure) and subsequent (chronic obstructive pulmonary disease) target conditions with a control group of nontarget conditions. Each model used 3 time periods: baseline (15 months before program announcement), an intervening period between announcement and implementation, and a 2‐year post‐implementation period, with specific dates defined by HRRP policies.Data Collection/Extraction Methods: We derived a 20% random sample of all hospitalizations for beneficiaries continuously enrolled for 12 months before hospitalization (N = 7,162,189).Principal Findings: Observation stays increased similarly for the initial HRRP target and nontarget conditions in the intervening period (0.01% points per month [95% CI −0.01, 0.3]). Post‐implementation, observation stays increased significantly more for target versus nontarget conditions, but the difference is quite small (0.02% points per month [95% CI 0.002, 0.04]). Results for the COPD analysis were statistically insignificant in both policy periods.Conclusions: The increase in observation stays is likely due to other factors, including audit activity and clinical advances.

The Hospital Readmissions Reduction Program (HRRP), legislated as part of the Patient Protection and Affordable Care Act (ACA), levies financial penalties on hospitals with higher-than-expected readmission rates for certain conditions. Several studies have suggested that the implementation of the HRRP was associated with modest decreases in readmissions shortly after the program was announced in 2010, especially for conditions and hospitals targeted by the program.^1-8

Expansion of Medicaid through the Affordable Care Act has been one of the most consequential health and social program reforms in recent decades. Since 2014, ap