Publications
1.
Kumar, Manish; Bond, Amelia M.; Khullar, Dhruv
County-Level Food Insecurity and Access to Medicare Advantage Food Benefits Journal Article
In: JAMA Network Open, vol. 8, iss. 12, 2025.
Abstract | Links | BibTeX | Tags: Telehealth and Artificial Intelligence
@article{nokey,
title = {County-Level Food Insecurity and Access to Medicare Advantage Food Benefits},
author = {Manish Kumar and Amelia M. Bond and Dhruv Khullar},
doi = {10.1001/jamanetworkopen.2025.48223},
year = {2025},
date = {2025-12-10},
journal = {JAMA Network Open},
volume = {8},
issue = {12},
abstract = {Nearly 17% of Medicare enrollees experience food insecurity,1 a share projected to increase following recent cuts to the Supplemental Nutrition Assistance Program.2 Since 2020, Medicare Advantage (MA) plans—which now enroll more than half of the Medicare population—have been able to offer a Food and Produce supplemental benefit, allowing plans to provide targeted allowances to beneficiaries to purchase healthy foods.
Supplemental benefits have drawn scrutiny, given mixed and incomplete evidence on how they are used and to whom they are offered.3-5 We examined the characteristics of plans offering the Food and Produce benefit in 2025 and assessed whether enrollment in these plans matched county-level need for nutritional support.},
keywords = {Telehealth and Artificial Intelligence},
pubstate = {published},
tppubtype = {article}
}
Nearly 17% of Medicare enrollees experience food insecurity,1 a share projected to increase following recent cuts to the Supplemental Nutrition Assistance Program.2 Since 2020, Medicare Advantage (MA) plans—which now enroll more than half of the Medicare population—have been able to offer a Food and Produce supplemental benefit, allowing plans to provide targeted allowances to beneficiaries to purchase healthy foods.
Supplemental benefits have drawn scrutiny, given mixed and incomplete evidence on how they are used and to whom they are offered.3-5 We examined the characteristics of plans offering the Food and Produce benefit in 2025 and assessed whether enrollment in these plans matched county-level need for nutritional support.
Supplemental benefits have drawn scrutiny, given mixed and incomplete evidence on how they are used and to whom they are offered.3-5 We examined the characteristics of plans offering the Food and Produce benefit in 2025 and assessed whether enrollment in these plans matched county-level need for nutritional support.
2.
Schpero, William L.; McConnell, John; Bushnell, Greta; Denham, Alina; Dow, Patience M.; Kapadia, Shashi N.; Lindner, Stephan R.; Samples, Hillary; Shea, Lindsay; Watson, Kelsey; Gordon, Sarah H.
The T-MSIS Analytic Files (TAF) Analysis Reporting Checklist Journal Article
In: JAMA Health Forum , vol. 6, iss. 10, 2025.
Abstract | Links | BibTeX | Tags: Drivers of Health
@article{nokey,
title = { The T-MSIS Analytic Files (TAF) Analysis Reporting Checklist},
author = {William L. Schpero and John McConnell and Greta Bushnell and Alina Denham and Patience M. Dow and Shashi N. Kapadia and Stephan R. Lindner and Hillary Samples and Lindsay Shea and Kelsey Watson and Sarah H. Gordon},
doi = {10.1001/jamahealthforum.2025.3622},
year = {2025},
date = {2025-10-24},
urldate = {2025-10-24},
journal = {JAMA Health Forum },
volume = {6},
issue = {10},
abstract = {Importance: Medicaid is the single largest source of health care coverage in the US, but health policy research on the Medicaid program has historically lagged research on Medicare due to limited availability of high-quality administrative claims data across states. In 2019, the US Centers for Medicare & Medicaid Services released the T-MSIS Analytic Files (TAF), a new-generation federal Medicaid claims dataset that has catalyzed policy-relevant research on the Medicaid program. TAF data are highly complex, however, with meaningful differences in quality across states, years, and data elements. There is an urgent need for standardized reporting guidelines to ensure TAF-based research is high quality and reproducible.
Objective: To develop a checklist to guide reporting of research using the TAF data.
Evidence review: The development of the TAF Analysis Reporting Checklist was led by a subcommittee of the Medicaid Data Learning Network (MDLN), a national consortium of research teams focused on developing and disseminating best practices for conducting health services research with the TAF data. The subcommittee first created a draft checklist drawing from published technical guidance on proper use of the TAF data, as well as published analyses of TAF data quality. This draft was iteratively refined based on feedback from (1) MDLN members; (2) the MDLN Advisory Group, composed of leaders in academia, government, and industry with Medicaid claims experience; (3) editors of health policy journals; and (4) the broader Medicaid research community.
Findings: The final checklist includes 4 categories of items that are recommended for reporting in studies using the TAF data. This includes (1) details on the specific data used (files, years, release versions, and size of the data extract), (2) how the analytic sample was defined (eligibility criteria, enrollment span, and scope of benefits), (3) what states and/or territories were excluded from the analysis based on data quality concerns (and the exclusion criteria used to do so), and (4) additional information on special considerations, including use of spending data and changes in data quality over time.
Conclusions and relevance: The TAF Analysis Reporting Checklist represents a consensus effort to identify items researchers should report to promote transparency and reproducibility in TAF-based studies. This reporting is a key step in safeguarding the quality of research used to inform Medicaid policy.},
keywords = {Drivers of Health},
pubstate = {published},
tppubtype = {article}
}
Importance: Medicaid is the single largest source of health care coverage in the US, but health policy research on the Medicaid program has historically lagged research on Medicare due to limited availability of high-quality administrative claims data across states. In 2019, the US Centers for Medicare & Medicaid Services released the T-MSIS Analytic Files (TAF), a new-generation federal Medicaid claims dataset that has catalyzed policy-relevant research on the Medicaid program. TAF data are highly complex, however, with meaningful differences in quality across states, years, and data elements. There is an urgent need for standardized reporting guidelines to ensure TAF-based research is high quality and reproducible.
Objective: To develop a checklist to guide reporting of research using the TAF data.
Evidence review: The development of the TAF Analysis Reporting Checklist was led by a subcommittee of the Medicaid Data Learning Network (MDLN), a national consortium of research teams focused on developing and disseminating best practices for conducting health services research with the TAF data. The subcommittee first created a draft checklist drawing from published technical guidance on proper use of the TAF data, as well as published analyses of TAF data quality. This draft was iteratively refined based on feedback from (1) MDLN members; (2) the MDLN Advisory Group, composed of leaders in academia, government, and industry with Medicaid claims experience; (3) editors of health policy journals; and (4) the broader Medicaid research community.
Findings: The final checklist includes 4 categories of items that are recommended for reporting in studies using the TAF data. This includes (1) details on the specific data used (files, years, release versions, and size of the data extract), (2) how the analytic sample was defined (eligibility criteria, enrollment span, and scope of benefits), (3) what states and/or territories were excluded from the analysis based on data quality concerns (and the exclusion criteria used to do so), and (4) additional information on special considerations, including use of spending data and changes in data quality over time.
Conclusions and relevance: The TAF Analysis Reporting Checklist represents a consensus effort to identify items researchers should report to promote transparency and reproducibility in TAF-based studies. This reporting is a key step in safeguarding the quality of research used to inform Medicaid policy.
Objective: To develop a checklist to guide reporting of research using the TAF data.
Evidence review: The development of the TAF Analysis Reporting Checklist was led by a subcommittee of the Medicaid Data Learning Network (MDLN), a national consortium of research teams focused on developing and disseminating best practices for conducting health services research with the TAF data. The subcommittee first created a draft checklist drawing from published technical guidance on proper use of the TAF data, as well as published analyses of TAF data quality. This draft was iteratively refined based on feedback from (1) MDLN members; (2) the MDLN Advisory Group, composed of leaders in academia, government, and industry with Medicaid claims experience; (3) editors of health policy journals; and (4) the broader Medicaid research community.
Findings: The final checklist includes 4 categories of items that are recommended for reporting in studies using the TAF data. This includes (1) details on the specific data used (files, years, release versions, and size of the data extract), (2) how the analytic sample was defined (eligibility criteria, enrollment span, and scope of benefits), (3) what states and/or territories were excluded from the analysis based on data quality concerns (and the exclusion criteria used to do so), and (4) additional information on special considerations, including use of spending data and changes in data quality over time.
Conclusions and relevance: The TAF Analysis Reporting Checklist represents a consensus effort to identify items researchers should report to promote transparency and reproducibility in TAF-based studies. This reporting is a key step in safeguarding the quality of research used to inform Medicaid policy.
3.
Connolly, John E.; Guido, Matthew; Girard, Anthony; Braun, Robert Tyler; Emanuel, Ezekiel J.
Changes in Payer Mix Associated With Private Equity Acquisition of Ophthalmology Practices Journal Article
In: JAMA Netw Open, vol. 8, no. 5, 2025.
Links | BibTeX | Tags: Corporatization and Consolidation
@article{nokey,
title = {Changes in Payer Mix Associated With Private Equity Acquisition of Ophthalmology Practices},
author = {John E. Connolly and Matthew Guido and Anthony Girard and Robert Tyler Braun and Ezekiel J. Emanuel},
doi = {10.1001/jamanetworkopen.2025.12629},
year = {2025},
date = {2025-05-28},
urldate = {2025-05-28},
journal = {JAMA Netw Open},
volume = {8},
number = {5},
keywords = {Corporatization and Consolidation},
pubstate = {published},
tppubtype = {article}
}
4.
Bond, Amelia M.; Civelek, Yasin; Schpero, William L.; Casalino, Lawrence P.; Zhang, Manyao; Pierre, Reekarl; Khullar, Dhruv
Long-Term Spending of Accountable Care Organizations in the Medicare Shared Savings Program Journal Article
In: JAMA, vol. 333, no. 21, pp. 1897-1905, 2025.
Abstract | Links | BibTeX | Tags: Payment Reform and Health Care Incentives
@article{nokey,
title = {Long-Term Spending of Accountable Care Organizations in the Medicare Shared Savings Program},
author = {Amelia M. Bond and Yasin Civelek and William L. Schpero and Lawrence P. Casalino and Manyao Zhang and Reekarl Pierre and Dhruv Khullar },
doi = {10.1001/jama.2025.3870},
year = {2025},
date = {2025-04-28},
urldate = {2025-04-28},
journal = {JAMA},
volume = {333},
number = {21},
pages = {1897-1905},
abstract = {Importance: Evidence from initial cohorts of accountable care organizations (ACOs) participating in the Medicare Shared Savings Program (MSSP) found modest reductions in health care spending. Little is known about whether these effects have changed over time.
Objective: To determine long-term changes in spending for MSSP ACO participants.
Design, Setting, and Participants: Using 2010 to 2019 traditional Medicare data, difference-in-differences analyses were performed to compare spending changes for patients attributed to ACOs relative to changes for patients at non-ACO organizations. Outcomes included total Medicare spending and spending by category. Three- and 6-year effects and estimated differential changes overall and by ACO characteristics were calculated, including size (small defined as <10 000 patients), rurality, and whether an ACO included a hospital (hospital-associated ACO) or not (physician-group ACO).
Exposure: Attribution to a medical group or clinic in an ACO during the first 2 years of ACO tenure.
Main Outcomes and Measures: Total annual per-patient Medicare spending.
Results: The sample included 41 973 272 Medicare patient-years. Baseline characteristics for 2 719 406 ACO patients and 5 523 652 control patients were similar (average age, 72 years; 58% female; and 82% to 84% White) prior to ACO formation in 2010 and 2011, and unadjusted annual per-patient spending was slightly lower in the ACO group vs control group ($12 147 vs $12 318; difference, −$171 [95% CI, −$223 to −$118]) in the 2 years prior to ACO formation. ACO formation was associated with a mean differential reduction of $142 (95% CI, −$193 to −$92) in annual per-patient spending over 3 years and $294 (95% CI, −$347 to −$241) over 6 years. Spending reductions associated with ACO formation increased over time: compared with control patients, ACO patients experienced a mean reduction of $234 (95% CI, −$298 to −$171) in year 3 and $584 (95% CI, −$680 to −$489) in year 6. Physician-group and small ACOs generated larger spending reductions. Spending changes resulted in $4.1 billion to $8.1 billion in savings to Medicare between 2012 and 2019.
Conclusions and Relevance: During the MSSP’s first decade, ACOs generated meaningful reductions in spending, with larger effects over time.},
keywords = {Payment Reform and Health Care Incentives},
pubstate = {published},
tppubtype = {article}
}
Importance: Evidence from initial cohorts of accountable care organizations (ACOs) participating in the Medicare Shared Savings Program (MSSP) found modest reductions in health care spending. Little is known about whether these effects have changed over time.
Objective: To determine long-term changes in spending for MSSP ACO participants.
Design, Setting, and Participants: Using 2010 to 2019 traditional Medicare data, difference-in-differences analyses were performed to compare spending changes for patients attributed to ACOs relative to changes for patients at non-ACO organizations. Outcomes included total Medicare spending and spending by category. Three- and 6-year effects and estimated differential changes overall and by ACO characteristics were calculated, including size (small defined as <10 000 patients), rurality, and whether an ACO included a hospital (hospital-associated ACO) or not (physician-group ACO).
Exposure: Attribution to a medical group or clinic in an ACO during the first 2 years of ACO tenure.
Main Outcomes and Measures: Total annual per-patient Medicare spending.
Results: The sample included 41 973 272 Medicare patient-years. Baseline characteristics for 2 719 406 ACO patients and 5 523 652 control patients were similar (average age, 72 years; 58% female; and 82% to 84% White) prior to ACO formation in 2010 and 2011, and unadjusted annual per-patient spending was slightly lower in the ACO group vs control group ($12 147 vs $12 318; difference, −$171 [95% CI, −$223 to −$118]) in the 2 years prior to ACO formation. ACO formation was associated with a mean differential reduction of $142 (95% CI, −$193 to −$92) in annual per-patient spending over 3 years and $294 (95% CI, −$347 to −$241) over 6 years. Spending reductions associated with ACO formation increased over time: compared with control patients, ACO patients experienced a mean reduction of $234 (95% CI, −$298 to −$171) in year 3 and $584 (95% CI, −$680 to −$489) in year 6. Physician-group and small ACOs generated larger spending reductions. Spending changes resulted in $4.1 billion to $8.1 billion in savings to Medicare between 2012 and 2019.
Conclusions and Relevance: During the MSSP’s first decade, ACOs generated meaningful reductions in spending, with larger effects over time.
Objective: To determine long-term changes in spending for MSSP ACO participants.
Design, Setting, and Participants: Using 2010 to 2019 traditional Medicare data, difference-in-differences analyses were performed to compare spending changes for patients attributed to ACOs relative to changes for patients at non-ACO organizations. Outcomes included total Medicare spending and spending by category. Three- and 6-year effects and estimated differential changes overall and by ACO characteristics were calculated, including size (small defined as <10 000 patients), rurality, and whether an ACO included a hospital (hospital-associated ACO) or not (physician-group ACO).
Exposure: Attribution to a medical group or clinic in an ACO during the first 2 years of ACO tenure.
Main Outcomes and Measures: Total annual per-patient Medicare spending.
Results: The sample included 41 973 272 Medicare patient-years. Baseline characteristics for 2 719 406 ACO patients and 5 523 652 control patients were similar (average age, 72 years; 58% female; and 82% to 84% White) prior to ACO formation in 2010 and 2011, and unadjusted annual per-patient spending was slightly lower in the ACO group vs control group ($12 147 vs $12 318; difference, −$171 [95% CI, −$223 to −$118]) in the 2 years prior to ACO formation. ACO formation was associated with a mean differential reduction of $142 (95% CI, −$193 to −$92) in annual per-patient spending over 3 years and $294 (95% CI, −$347 to −$241) over 6 years. Spending reductions associated with ACO formation increased over time: compared with control patients, ACO patients experienced a mean reduction of $234 (95% CI, −$298 to −$171) in year 3 and $584 (95% CI, −$680 to −$489) in year 6. Physician-group and small ACOs generated larger spending reductions. Spending changes resulted in $4.1 billion to $8.1 billion in savings to Medicare between 2012 and 2019.
Conclusions and Relevance: During the MSSP’s first decade, ACOs generated meaningful reductions in spending, with larger effects over time.
5.
Bond, Amelia M.; Schpero, William L.; Civelek, Yasin; Tormohlen, Kayla; Casalino, Lawrence P.; Jones, David J.; Zhang, Manyao; Pierre, Reekarl; Khullar, Dhruv
Changes in Primary Care Practice Setting and Practice Type for Medicare Beneficiaries Journal Article
In: JAMA Health Forum , vol. 6, iss. 4, 2025.
Abstract | Links | BibTeX | Tags: Payment Reform and Health Care Incentives
@article{nokey,
title = {Changes in Primary Care Practice Setting and Practice Type for Medicare Beneficiaries},
author = {Amelia M. Bond and William L. Schpero and Yasin Civelek and Kayla Tormohlen and Lawrence P. Casalino and David J. Jones and Manyao Zhang and Reekarl Pierre and Dhruv Khullar },
doi = {10.1001/jamahealthforum.2025.0445},
year = {2025},
date = {2025-04-25},
journal = {JAMA Health Forum },
volume = {6},
issue = {4},
abstract = {This cross-sectional study examined changes in practice setting and practice type in 2012 vs 2022 among patients with traditional Medicare coverage.},
keywords = {Payment Reform and Health Care Incentives},
pubstate = {published},
tppubtype = {article}
}
This cross-sectional study examined changes in practice setting and practice type in 2012 vs 2022 among patients with traditional Medicare coverage.
6.
Yu, Jiani; Casalino, Lawrence P; Jung, Hye-Young; Lake, Derek; Zhang, Manyao; Pierre, Reekarl; Khullar, Dhruv
Utilization and Quality Among Medicare Advantage Beneficiaries with High Vs Low Access to Telehealth Journal Article
In: Health Affairs Scholar , 2025.
Abstract | Links | BibTeX | Tags: Payment Reform and Health Care Incentives
@article{nokey,
title = {Utilization and Quality Among Medicare Advantage Beneficiaries with High Vs Low Access to Telehealth },
author = {Jiani Yu and Lawrence P Casalino and Hye-Young Jung and Derek Lake and Manyao Zhang and Reekarl Pierre and Dhruv Khullar},
doi = {10.1093/haschl/qxaf064},
year = {2025},
date = {2025-03-26},
urldate = {2025-03-26},
journal = {Health Affairs Scholar },
abstract = {Introduction
Access to telehealth care has increased markedly in recent years, especially for patients in the Medicare Advantage (MA) program. Given the unique features of MA, such as capitated payment and provider networks, understanding the impact of telehealth availability on quality, costs, and utilization is important for informing coverage and payment decisions.
Methods
We compared quality and utilization outcomes among MA beneficiaries with varying access to telehealth, using MA encounter data from a 20% national random sample of enrollees from 2019-2021.
Results
We found that high-telehealth access was associated with a 13.4% decrease in in-person evaluation and management (E&M) visits, relative to the period prior to the pandemic onset. Given that this decrease was offset by increases in telehealth E&M visits, there was no change in total E&M visits. High-telehealth access was also associated with a 4.8% decrease in total ED visits, but no differences in preventable ED visits, total hospital admissions, or ambulatory care-sensitive admissions.
Conclusions
Increases in telehealth-delivered E&M visits among MA beneficiaries with high telehealth access offset decreases in in-person-delivered E&M visits. These findings may help clinicians and policymakers contextualize the relationship between broader access to telehealth for MA enrollees and various types of health care utilization.},
keywords = {Payment Reform and Health Care Incentives},
pubstate = {published},
tppubtype = {article}
}
Introduction
Access to telehealth care has increased markedly in recent years, especially for patients in the Medicare Advantage (MA) program. Given the unique features of MA, such as capitated payment and provider networks, understanding the impact of telehealth availability on quality, costs, and utilization is important for informing coverage and payment decisions.
Methods
We compared quality and utilization outcomes among MA beneficiaries with varying access to telehealth, using MA encounter data from a 20% national random sample of enrollees from 2019-2021.
Results
We found that high-telehealth access was associated with a 13.4% decrease in in-person evaluation and management (E&M) visits, relative to the period prior to the pandemic onset. Given that this decrease was offset by increases in telehealth E&M visits, there was no change in total E&M visits. High-telehealth access was also associated with a 4.8% decrease in total ED visits, but no differences in preventable ED visits, total hospital admissions, or ambulatory care-sensitive admissions.
Conclusions
Increases in telehealth-delivered E&M visits among MA beneficiaries with high telehealth access offset decreases in in-person-delivered E&M visits. These findings may help clinicians and policymakers contextualize the relationship between broader access to telehealth for MA enrollees and various types of health care utilization.
Access to telehealth care has increased markedly in recent years, especially for patients in the Medicare Advantage (MA) program. Given the unique features of MA, such as capitated payment and provider networks, understanding the impact of telehealth availability on quality, costs, and utilization is important for informing coverage and payment decisions.
Methods
We compared quality and utilization outcomes among MA beneficiaries with varying access to telehealth, using MA encounter data from a 20% national random sample of enrollees from 2019-2021.
Results
We found that high-telehealth access was associated with a 13.4% decrease in in-person evaluation and management (E&M) visits, relative to the period prior to the pandemic onset. Given that this decrease was offset by increases in telehealth E&M visits, there was no change in total E&M visits. High-telehealth access was also associated with a 4.8% decrease in total ED visits, but no differences in preventable ED visits, total hospital admissions, or ambulatory care-sensitive admissions.
Conclusions
Increases in telehealth-delivered E&M visits among MA beneficiaries with high telehealth access offset decreases in in-person-delivered E&M visits. These findings may help clinicians and policymakers contextualize the relationship between broader access to telehealth for MA enrollees and various types of health care utilization.
7.
Casalino, Lawrence P.; Bond, Amelia M.; Khullar, Dhruv
Steering, Switching, and the Medicare Advantage “Trap” Journal Article
In: JAMA, iss. JAMA, 2025.
Links | BibTeX | Tags: Payment Reform and Health Care Incentives
@article{nokey,
title = {Steering, Switching, and the Medicare Advantage “Trap”},
author = { Lawrence P. Casalino and Amelia M. Bond and Dhruv Khullar },
doi = {10.1001/jama.2025.1759},
year = {2025},
date = {2025-03-17},
urldate = {2025-03-17},
journal = {JAMA},
issue = {JAMA},
publisher = {JAMA},
howpublished = {Online},
keywords = {Payment Reform and Health Care Incentives},
pubstate = {published},
tppubtype = {article}
}
8.
Khullar, Dhruv; Young, Dannagal G.
Misinformation, Identity, and the Basis of Belief Journal Article
In: Annals of Internal Medicine , vol. 0, iss. 0, 2024.
Links | BibTeX | Tags: Medical Professionalism and Physician Well-being
@article{nokey,
title = {Misinformation, Identity, and the Basis of Belief},
author = {Dhruv Khullar and Dannagal G. Young},
url = {https://www.acpjournals.org/doi/10.7326/ANNALS-24-02844},
year = {2024},
date = {2024-12-31},
journal = {Annals of Internal Medicine },
volume = {0},
issue = {0},
keywords = {Medical Professionalism and Physician Well-being},
pubstate = {published},
tppubtype = {article}
}
9.
Casalino, Lawrence P.; Karig, Shachar; Markovits, Daniel; Fisman, Raymond; Li, Jing
Physician Altruism and Spending, Hospital Admissions, and Emergency Department Visits Journal Article
In: JAMA Health Forum, vol. 5, no. 10, 2024.
Abstract | Links | BibTeX | Tags: Medical Professionalism and Physician Well-being
@article{nokey,
title = {Physician Altruism and Spending, Hospital Admissions, and Emergency Department Visits},
author = {Lawrence P. Casalino and Shachar Karig and Daniel Markovits and Raymond Fisman and Jing Li},
url = {https://edhub.ama-assn.org/jn-learning/audio-player/18918894 },
doi = {10.1001/jamahealthforum.2024.3383},
year = {2024},
date = {2024-10-11},
urldate = {2024-10-11},
journal = {JAMA Health Forum},
volume = {5},
number = {10},
abstract = {Importance
Altruism—putting the patient first—is a fundamental component of physician professionalism. Evidence is lacking about the relationship between physician altruism, care quality, and spending.
Objective
To determine whether there is a relationship between physician altruism, measures of quality, and spending, hypothesizing that altruistic physicians have better results.
Design, Setting, and Participants
This cross-sectional study that used a validated economic experiment to measure altruism was carried out between October 2018 and November 2019 using a nationwide sample of US primary care physicians and cardiologists. Altruism data were linked to 2019 Medicare claims and multivariable regressions were used to examine the relationship between altruism and quality and spending measures. Overall, 250 physicians in 43 medical practices that varied in size, location, and ownership, and 7626 Medicare fee-for-service beneficiaries attributed to the physicians were included. The analysis was conducted from April 2022 to August 2024.
Exposure
Physicians completed a widely used modified dictator-game style web-based experiment; based on their responses, they were categorized as more or less altruistic.
Main Measures
Potentially preventable hospital admissions, potentially preventable emergency department visits, and Medicare spending.
Results
In all, 1599 beneficiaries (21%) were attributed to the 45 physicians (18%) categorized as altruistic and 6027 patients were attributed to the 205 physicians not categorized as altruistic. Adjusting for patient, physician, and practice characteristics, patients of altruistic physicians had a lower likelihood of any potentially preventable admission (odds ratio [OR], 0.60; 95% CI, 0.38-0.97; P = .03) and any potentially preventable emergency department visit (OR, 0.64; CI, 0.43-0.94; P = .02). Adjusted spending was 9.26% lower (95% CI, −16.24% to −2.27%; P = .01).
Conclusions and Relevance
This cross-sectional study found that Medicare patients treated by altruistic physicians had fewer potentially preventable hospitalizations and emergency department visits and lower spending. Policymakers and leaders of hospitals, medical practices, and medical schools may want to consider creating incentives, organizational structures, and cultures that may increase, or at least do not decrease, physician altruism. Further research should seek to identify these and other modifiable factors, such as physician selection and training, that may shape physician altruism. Research could also analyze the relationship between altruism and quality and spending in additional medical practices, specialties, and countries, and use additional measures of quality and of patient experience.},
keywords = {Medical Professionalism and Physician Well-being},
pubstate = {published},
tppubtype = {article}
}
Importance
Altruism—putting the patient first—is a fundamental component of physician professionalism. Evidence is lacking about the relationship between physician altruism, care quality, and spending.
Objective
To determine whether there is a relationship between physician altruism, measures of quality, and spending, hypothesizing that altruistic physicians have better results.
Design, Setting, and Participants
This cross-sectional study that used a validated economic experiment to measure altruism was carried out between October 2018 and November 2019 using a nationwide sample of US primary care physicians and cardiologists. Altruism data were linked to 2019 Medicare claims and multivariable regressions were used to examine the relationship between altruism and quality and spending measures. Overall, 250 physicians in 43 medical practices that varied in size, location, and ownership, and 7626 Medicare fee-for-service beneficiaries attributed to the physicians were included. The analysis was conducted from April 2022 to August 2024.
Exposure
Physicians completed a widely used modified dictator-game style web-based experiment; based on their responses, they were categorized as more or less altruistic.
Main Measures
Potentially preventable hospital admissions, potentially preventable emergency department visits, and Medicare spending.
Results
In all, 1599 beneficiaries (21%) were attributed to the 45 physicians (18%) categorized as altruistic and 6027 patients were attributed to the 205 physicians not categorized as altruistic. Adjusting for patient, physician, and practice characteristics, patients of altruistic physicians had a lower likelihood of any potentially preventable admission (odds ratio [OR], 0.60; 95% CI, 0.38-0.97; P = .03) and any potentially preventable emergency department visit (OR, 0.64; CI, 0.43-0.94; P = .02). Adjusted spending was 9.26% lower (95% CI, −16.24% to −2.27%; P = .01).
Conclusions and Relevance
This cross-sectional study found that Medicare patients treated by altruistic physicians had fewer potentially preventable hospitalizations and emergency department visits and lower spending. Policymakers and leaders of hospitals, medical practices, and medical schools may want to consider creating incentives, organizational structures, and cultures that may increase, or at least do not decrease, physician altruism. Further research should seek to identify these and other modifiable factors, such as physician selection and training, that may shape physician altruism. Research could also analyze the relationship between altruism and quality and spending in additional medical practices, specialties, and countries, and use additional measures of quality and of patient experience.
Altruism—putting the patient first—is a fundamental component of physician professionalism. Evidence is lacking about the relationship between physician altruism, care quality, and spending.
Objective
To determine whether there is a relationship between physician altruism, measures of quality, and spending, hypothesizing that altruistic physicians have better results.
Design, Setting, and Participants
This cross-sectional study that used a validated economic experiment to measure altruism was carried out between October 2018 and November 2019 using a nationwide sample of US primary care physicians and cardiologists. Altruism data were linked to 2019 Medicare claims and multivariable regressions were used to examine the relationship between altruism and quality and spending measures. Overall, 250 physicians in 43 medical practices that varied in size, location, and ownership, and 7626 Medicare fee-for-service beneficiaries attributed to the physicians were included. The analysis was conducted from April 2022 to August 2024.
Exposure
Physicians completed a widely used modified dictator-game style web-based experiment; based on their responses, they were categorized as more or less altruistic.
Main Measures
Potentially preventable hospital admissions, potentially preventable emergency department visits, and Medicare spending.
Results
In all, 1599 beneficiaries (21%) were attributed to the 45 physicians (18%) categorized as altruistic and 6027 patients were attributed to the 205 physicians not categorized as altruistic. Adjusting for patient, physician, and practice characteristics, patients of altruistic physicians had a lower likelihood of any potentially preventable admission (odds ratio [OR], 0.60; 95% CI, 0.38-0.97; P = .03) and any potentially preventable emergency department visit (OR, 0.64; CI, 0.43-0.94; P = .02). Adjusted spending was 9.26% lower (95% CI, −16.24% to −2.27%; P = .01).
Conclusions and Relevance
This cross-sectional study found that Medicare patients treated by altruistic physicians had fewer potentially preventable hospitalizations and emergency department visits and lower spending. Policymakers and leaders of hospitals, medical practices, and medical schools may want to consider creating incentives, organizational structures, and cultures that may increase, or at least do not decrease, physician altruism. Further research should seek to identify these and other modifiable factors, such as physician selection and training, that may shape physician altruism. Research could also analyze the relationship between altruism and quality and spending in additional medical practices, specialties, and countries, and use additional measures of quality and of patient experience.
10.
Yu, Jiani; Civelek, Yasin; Casalino, Lawrence P.; Jung, Hye-Young; Pierre, Reekarl; Zhang, Manyao; Khullar, Dhruv
Telehealth Delivery Differs Significantly By Physician And Practice Characteristics Journal Article
In: Health Affairs , vol. 43, iss. 9, pp. 1311-1318, 2024.
Abstract | Links | BibTeX | Tags: Telehealth and Artificial Intelligence
@article{nokey,
title = {Telehealth Delivery Differs Significantly By Physician And Practice Characteristics},
author = {Jiani Yu and Yasin Civelek and Lawrence P. Casalino and Hye-Young Jung and Reekarl Pierre and Manyao Zhang and Dhruv Khullar},
doi = {10.1377/hlthaff.2024.00052},
year = {2024},
date = {2024-09-03},
urldate = {2024-09-03},
journal = {Health Affairs },
volume = {43},
issue = {9},
pages = {1311-1318},
abstract = {In this study of 2022 Medicare fee-for-service claims, we found that female physicians, primary care physicians, psychiatrists, and physicians in nonrural practices delivered relatively higher proportions of visits via telehealth.},
keywords = {Telehealth and Artificial Intelligence},
pubstate = {published},
tppubtype = {article}
}
In this study of 2022 Medicare fee-for-service claims, we found that female physicians, primary care physicians, psychiatrists, and physicians in nonrural practices delivered relatively higher proportions of visits via telehealth.
11.
Khullar, Dhruv; Schpero, William L.; Casalino, Lawrence P.; Pierre, Reekarl; Carter, Samuel; Civelek, Yasin; Zhang, Manyao; Bond, Amelia M.
Meeting The Needs Of Socially Vulnerable Patients: Views Of ACO Leaders On Moving From Intent To Action Journal Article
In: Health Affairs , vol. 43, no. 8, 2024.
Abstract | Links | BibTeX | Tags: Payment Reform and Health Care Incentives
@article{nokey,
title = {Meeting The Needs Of Socially Vulnerable Patients: Views Of ACO Leaders On Moving From Intent To Action},
author = {Dhruv Khullar and William L. Schpero and Lawrence P. Casalino and Reekarl Pierre and Samuel Carter and Yasin Civelek and Manyao Zhang and Amelia M. Bond},
doi = {10.1377/hlthaff.2023.00673},
year = {2024},
date = {2024-08-05},
urldate = {2024-08-05},
journal = {Health Affairs },
volume = {43},
number = {8},
abstract = {The Centers for Medicare and Medicaid Services has placed growing emphasis on social drivers of health, but little is known about how accountable care organizations (ACOs) aim to meet the needs of vulnerable patients. During September–December 2022, we interviewed leaders of forty-nine ACOs participating in the Medicare Shared Savings Program (MSSP). Participants were asked about strategies to identify socially vulnerable patients, programs that addressed their needs, and Medicare reforms that could support their efforts. Seven themes emerged: ACOs were in the early stages of collecting social needs data; leaders were frustrated by an incomplete ability to act on such data; ACOs tended to stratify patients by medical, rather than social, risk; some ACOs have introduced pilot programs to address challenges, including social isolation and drug costs; programs were often payer agnostic; rural ACOs faced unique challenges; and Medicare reforms related to reimbursement, logistical support, quality metrics, and patient benefits could support ACO efforts. These findings suggest that the MSSP alone has not been sufficient to promote consistent investment in social needs provision at most ACOs. Policy makers may want to consider more direct support and incentives for health care organizations, or greater investment in non–health care sectors, to help socially vulnerable patients.},
keywords = {Payment Reform and Health Care Incentives},
pubstate = {published},
tppubtype = {article}
}
The Centers for Medicare and Medicaid Services has placed growing emphasis on social drivers of health, but little is known about how accountable care organizations (ACOs) aim to meet the needs of vulnerable patients. During September–December 2022, we interviewed leaders of forty-nine ACOs participating in the Medicare Shared Savings Program (MSSP). Participants were asked about strategies to identify socially vulnerable patients, programs that addressed their needs, and Medicare reforms that could support their efforts. Seven themes emerged: ACOs were in the early stages of collecting social needs data; leaders were frustrated by an incomplete ability to act on such data; ACOs tended to stratify patients by medical, rather than social, risk; some ACOs have introduced pilot programs to address challenges, including social isolation and drug costs; programs were often payer agnostic; rural ACOs faced unique challenges; and Medicare reforms related to reimbursement, logistical support, quality metrics, and patient benefits could support ACO efforts. These findings suggest that the MSSP alone has not been sufficient to promote consistent investment in social needs provision at most ACOs. Policy makers may want to consider more direct support and incentives for health care organizations, or greater investment in non–health care sectors, to help socially vulnerable patients.
12.
Yu, Jiani; Civelek, Yasin; Casalino, Lawrence P.; Jung, Hye-Young; Zhang, Manyao; Pierre, Reekarl; Khullar, Dhruv
Audio-Only Telehealth Use Among Traditional Medicare Beneficiaries Journal Article
In: JAMA Health Forum, 2024.
Abstract | Links | BibTeX | Tags: Telehealth and Artificial Intelligence
@article{nokey_40,
title = {Audio-Only Telehealth Use Among Traditional Medicare Beneficiaries},
author = {Jiani Yu and Yasin Civelek and Lawrence P. Casalino and Hye-Young Jung and Manyao Zhang and Reekarl Pierre and Dhruv Khullar},
doi = {10.1001/jamahealthforum.2024.0442},
year = {2024},
date = {2024-05-10},
urldate = {2024-05-10},
journal = {JAMA Health Forum},
abstract = {Medicare expanded telehealth coverage during the COVID-19 pandemic, including for audio-only visits. Audio-only visits may be accessible to individuals lacking reliable internet for video visits; however, some have argued that these visits may lead to poorer quality care, increased costs, and fraudulent claims.1,2 Except for audio-only mental health visits, Medicare reimbursement for audio-only visits will expire after December 2024. We analyzed how audio-only telehealth use has changed over time and which patients would be most affected by policy reforms.},
keywords = {Telehealth and Artificial Intelligence},
pubstate = {published},
tppubtype = {article}
}
Medicare expanded telehealth coverage during the COVID-19 pandemic, including for audio-only visits. Audio-only visits may be accessible to individuals lacking reliable internet for video visits; however, some have argued that these visits may lead to poorer quality care, increased costs, and fraudulent claims.1,2 Except for audio-only mental health visits, Medicare reimbursement for audio-only visits will expire after December 2024. We analyzed how audio-only telehealth use has changed over time and which patients would be most affected by policy reforms.
13.
Khullar, Dhruv; Schpero, William L.; Casalino, Lawrence P.; Pierre, Reekarl; Carter, Samuel; Civelek, Yasin; Zhang, Manyao; Bond, Amelia M.
Accountable Care Organization Leader Perspectives on the Medicare Shared Savings Program Journal Article
In: JAMA Health Forum, 2024.
Abstract | Links | BibTeX | Tags: Payment Reform and Health Care Incentives
@article{nokey,
title = {Accountable Care Organization Leader Perspectives on the Medicare Shared Savings Program},
author = {Dhruv Khullar and William L. Schpero and Lawrence P. Casalino and Reekarl Pierre and Samuel Carter and Yasin Civelek and Manyao Zhang and Amelia M. Bond},
doi = {10.1001/jamahealthforum.2024.0126},
year = {2024},
date = {2024-03-15},
journal = {JAMA Health Forum},
abstract = {Importance
The Medicare Shared Savings Program (MSSP) includes more than 400 accountable care organizations (ACOs) and is among the largest and longest running value-based payment efforts in the US. However, given recent program reforms and other changes in the health care system, the experiences and perspectives of ACO leaders remain incompletely characterized.
Objective
To understand the priorities, strategies, and challenges of ACO leaders in MSSP.
Design, Setting, and Participants
In this qualitative study, interviews were conducted with leaders of 49 ACOs of differing sizes, leadership structures, and geographies from MSSP between September 29 and December 29, 2022. Participants were asked about their clinical and care management efforts; how they engaged frontline clinicians; the process by which they distributed shared savings and added or removed practices; and other factors that they believed influenced their success or failure in the program.
Main Outcomes and Measures
Leader perspectives on major themes related to ACO initiatives, performance improvement, and the recruitment, engagement, and retention of clinicians.
Results
Of the 49 ACOs interviewed, 34 were hospital-associated ACOs (69%), 35 were medium or large (>10 000 attributed beneficiaries) (71%), and 17 were rural (35%). The ACOs had a mean (SD) tenure of 8.1 (2.1) years in MSSP. Five major themes emerged: (1) ACO leaders reported a focus on annual wellness visits, coding practices, and care transitions; (2) leaders used both relationship-based and metrics-based strategies to promote clinician engagement; (3) ACOs generally distributed half or more of shared savings to participating practices; (4) ACO recruitment and retention efforts were increasingly influenced by market competition; and (5) some hospital-associated ACOs faced misaligned incentives.
Conclusions and Relevance
In this study, the ACO leaders reported varied approaches to promoting clinician alignment with ACO goals, an emphasis on increasing annual wellness visits, and new pressures related to growth of other care models. Policymakers hoping to modify or expand the program may wish to incorporate these perspectives into future reforms.
},
keywords = {Payment Reform and Health Care Incentives},
pubstate = {published},
tppubtype = {article}
}
Importance
The Medicare Shared Savings Program (MSSP) includes more than 400 accountable care organizations (ACOs) and is among the largest and longest running value-based payment efforts in the US. However, given recent program reforms and other changes in the health care system, the experiences and perspectives of ACO leaders remain incompletely characterized.
Objective
To understand the priorities, strategies, and challenges of ACO leaders in MSSP.
Design, Setting, and Participants
In this qualitative study, interviews were conducted with leaders of 49 ACOs of differing sizes, leadership structures, and geographies from MSSP between September 29 and December 29, 2022. Participants were asked about their clinical and care management efforts; how they engaged frontline clinicians; the process by which they distributed shared savings and added or removed practices; and other factors that they believed influenced their success or failure in the program.
Main Outcomes and Measures
Leader perspectives on major themes related to ACO initiatives, performance improvement, and the recruitment, engagement, and retention of clinicians.
Results
Of the 49 ACOs interviewed, 34 were hospital-associated ACOs (69%), 35 were medium or large (>10 000 attributed beneficiaries) (71%), and 17 were rural (35%). The ACOs had a mean (SD) tenure of 8.1 (2.1) years in MSSP. Five major themes emerged: (1) ACO leaders reported a focus on annual wellness visits, coding practices, and care transitions; (2) leaders used both relationship-based and metrics-based strategies to promote clinician engagement; (3) ACOs generally distributed half or more of shared savings to participating practices; (4) ACO recruitment and retention efforts were increasingly influenced by market competition; and (5) some hospital-associated ACOs faced misaligned incentives.
Conclusions and Relevance
In this study, the ACO leaders reported varied approaches to promoting clinician alignment with ACO goals, an emphasis on increasing annual wellness visits, and new pressures related to growth of other care models. Policymakers hoping to modify or expand the program may wish to incorporate these perspectives into future reforms.
The Medicare Shared Savings Program (MSSP) includes more than 400 accountable care organizations (ACOs) and is among the largest and longest running value-based payment efforts in the US. However, given recent program reforms and other changes in the health care system, the experiences and perspectives of ACO leaders remain incompletely characterized.
Objective
To understand the priorities, strategies, and challenges of ACO leaders in MSSP.
Design, Setting, and Participants
In this qualitative study, interviews were conducted with leaders of 49 ACOs of differing sizes, leadership structures, and geographies from MSSP between September 29 and December 29, 2022. Participants were asked about their clinical and care management efforts; how they engaged frontline clinicians; the process by which they distributed shared savings and added or removed practices; and other factors that they believed influenced their success or failure in the program.
Main Outcomes and Measures
Leader perspectives on major themes related to ACO initiatives, performance improvement, and the recruitment, engagement, and retention of clinicians.
Results
Of the 49 ACOs interviewed, 34 were hospital-associated ACOs (69%), 35 were medium or large (>10 000 attributed beneficiaries) (71%), and 17 were rural (35%). The ACOs had a mean (SD) tenure of 8.1 (2.1) years in MSSP. Five major themes emerged: (1) ACO leaders reported a focus on annual wellness visits, coding practices, and care transitions; (2) leaders used both relationship-based and metrics-based strategies to promote clinician engagement; (3) ACOs generally distributed half or more of shared savings to participating practices; (4) ACO recruitment and retention efforts were increasingly influenced by market competition; and (5) some hospital-associated ACOs faced misaligned incentives.
Conclusions and Relevance
In this study, the ACO leaders reported varied approaches to promoting clinician alignment with ACO goals, an emphasis on increasing annual wellness visits, and new pressures related to growth of other care models. Policymakers hoping to modify or expand the program may wish to incorporate these perspectives into future reforms.
14.
Khullar, Dhruv; Casalino, Lawrence P.; Bond, Amelia M.
Vertical Integration and the Transformation of American Medicine Journal Article
In: The New England Journal of Medicine, 2024.
Links | BibTeX | Tags: Corporatization and Consolidation
@article{nokey,
title = {Vertical Integration and the Transformation of American Medicine},
author = {Dhruv Khullar and Lawrence P. Casalino and Amelia M. Bond},
doi = {10.1056/NEJMp2313406},
year = {2024},
date = {2024-03-14},
journal = {The New England Journal of Medicine},
keywords = {Corporatization and Consolidation},
pubstate = {published},
tppubtype = {article}
}
15.
Khullar, Dhruv; Wang, Xingbo; Wang, Fei
Large Language Models in Health Care: Charting a Path Toward Accurate, Explainable, and Secure AI Journal Article
In: Journal of General Internal Medicine, vol. 39, iss. 3, 2024.
Links | BibTeX | Tags: Telehealth and Artificial Intelligence
@article{nokey,
title = {Large Language Models in Health Care: Charting a Path Toward Accurate, Explainable, and Secure AI},
author = {Dhruv Khullar and Xingbo Wang and Fei Wang},
doi = {https://doi.org/10.1007/s11606-024-08657-2},
year = {2024},
date = {2024-02-02},
urldate = {2024-02-02},
journal = {Journal of General Internal Medicine},
volume = {39},
issue = {3},
keywords = {Telehealth and Artificial Intelligence},
pubstate = {published},
tppubtype = {article}
}
16.
Schpero, William L.; Brahmbhatt, Diksha; Liu, Michael X.; Ndumele, Chima D.; Chatterjee, Paula
Variation in Procedural Denials of Medicaid Eligibility Across States Before the COVID-19 Pandemic Journal Article
In: JAMA Health Forum , vol. 4, no. 11, 2023.
Links | BibTeX | Tags: Payment Reform and Health Care Incentives
@article{nokey,
title = {Variation in Procedural Denials of Medicaid Eligibility Across States Before the COVID-19 Pandemic},
author = {William L. Schpero and Diksha Brahmbhatt and Michael X. Liu and Chima D. Ndumele and Paula Chatterjee},
doi = {10.1001/jamahealthforum.2023.3892},
year = {2023},
date = {2023-11-11},
urldate = {2023-11-11},
journal = {JAMA Health Forum },
volume = {4},
number = {11},
keywords = {Payment Reform and Health Care Incentives},
pubstate = {published},
tppubtype = {article}
}
17.
Zhang, Yongkang; Luth, Elizabeth A; Phongtankuel, Veerawat; Ling, Wodan; Zhang, Manyao; Shao, Hui
2023.
Links | BibTeX | Tags: Drivers of Health
@bachelorthesis{nokey,
title = {Factors associated with preventable hospitalizations after hospice live discharge among Medicare patients with Alzheimer's disease and related dementias},
author = {Yongkang Zhang and Elizabeth A Luth and Veerawat Phongtankuel and Wodan Ling and Manyao Zhang and Hui Shao},
doi = {10.1111/jgs.18505},
year = {2023},
date = {2023-11-07},
journal = {Journal of the American Geriatrics Society },
volume = {71},
issue = {11},
pages = {3631-3635},
keywords = {Drivers of Health},
pubstate = {published},
tppubtype = {bachelorthesis}
}
18.
Braun, Robert Tyler; Lelli, Gary Joseph; Pandey, Abhinav; Zhang, Manyao; Winebrake, James P.; Casalino, Lawrence P.
Association of Private Equity Firm Acquisition of Ophthalmology Practices with Medicare Spending and Use of Ophthalmology Services Journal Article
In: American Academy of Opthalmology , vol. 131, iss. 3, pp. 360-369, 2023.
Abstract | Links | BibTeX | Tags: Corporatization and Consolidation
@article{nokey,
title = {Association of Private Equity Firm Acquisition of Ophthalmology Practices with Medicare Spending and Use of Ophthalmology Services},
author = {Robert Tyler Braun and Gary Joseph Lelli and Abhinav Pandey and Manyao Zhang and James P. Winebrake and Lawrence P. Casalino},
doi = {10.1016/j.ophtha.2023.09.029},
year = {2023},
date = {2023-09-28},
journal = {American Academy of Opthalmology },
volume = {131},
issue = {3},
pages = {360-369},
abstract = {Purpose
Private equity (PE) firms increasingly are acquiring ophthalmology practices; little is known of their influence on care use and spending. We studied changes in use and Medicare spending after PE acquisition.
Design
Retrospective cohort study.
Participants
Seven hundred sixty-two clinicians in 123 practices acquired by PE between 2017 and 2018 and 34 807 clinicians in 20 549 never-acquired practices.
Methods
We analyzed Medicare fee-for-service claims (2012–2019) combined with a novel national database of PE acquisitions of ophthalmology practices using a difference-in-differences method within an event study framework to compare changes after a practice was acquired with changes in practices that were not acquired.
Main Outcome Measures
Numbers of beneficiaries seen; intravitreal injections and medications used for injections; and spending on ophthalmologist and optometrist services, ancillary services, and intravitreal injections.
Results
Comparing PE-acquired with nonacquired practices showed a 23.92% increase (n = 4.20 beneficiaries; 95% confidence interval [CI], 1.73–6.67) in beneficiaries seen per PE optometrist per quarter and no change for ophthalmologists, while spending per beneficiary increased 5.06% ($9.66; 95% CI, –2.82 to 22.14). Spending on clinician services decreased 1.62% (–$2.37; 95% CI, –5.78 to 1.04), with ophthalmologist services increasing 5.46% ($17.70; 95% CI, –2.73 to 38.15) and optometrists decreasing 4.60% (–$5.76; 95% CI, –9.17 to –2.34) per beneficiary per quarter. Ancillary services decreased 7.56% (–$2.19; 95% CI, 4.19 to –0.22). Intravitreal injection costs increased 25.0% ($20.02; 95% CI, –1.38 to 41.41) with the number increasing 5.10% (1.83; 95% CI, –0.1 to 3.80). There was a 74.09% increase (8.38 injections; 95% CI, 0.01–16.74) in ranibizumab and a 12.91% decrease (–3.40 injections; 95% CI, –6.86 to 0.07) in bevacizumab after acquisition. The event study showed consistent and often statistically significant increases in ranibizumab injections and decreases in bevacizumab injections after acquisition.
Conclusions
Although not all results reached statistical significance, this study suggested that PE acquisition of practices showed little or no overall effect on use or total spending, but increased the number of unique patients seen per optometrist and the use of expensive intravitreal injections.},
keywords = {Corporatization and Consolidation},
pubstate = {published},
tppubtype = {article}
}
Purpose
Private equity (PE) firms increasingly are acquiring ophthalmology practices; little is known of their influence on care use and spending. We studied changes in use and Medicare spending after PE acquisition.
Design
Retrospective cohort study.
Participants
Seven hundred sixty-two clinicians in 123 practices acquired by PE between 2017 and 2018 and 34 807 clinicians in 20 549 never-acquired practices.
Methods
We analyzed Medicare fee-for-service claims (2012–2019) combined with a novel national database of PE acquisitions of ophthalmology practices using a difference-in-differences method within an event study framework to compare changes after a practice was acquired with changes in practices that were not acquired.
Main Outcome Measures
Numbers of beneficiaries seen; intravitreal injections and medications used for injections; and spending on ophthalmologist and optometrist services, ancillary services, and intravitreal injections.
Results
Comparing PE-acquired with nonacquired practices showed a 23.92% increase (n = 4.20 beneficiaries; 95% confidence interval [CI], 1.73–6.67) in beneficiaries seen per PE optometrist per quarter and no change for ophthalmologists, while spending per beneficiary increased 5.06% ($9.66; 95% CI, –2.82 to 22.14). Spending on clinician services decreased 1.62% (–$2.37; 95% CI, –5.78 to 1.04), with ophthalmologist services increasing 5.46% ($17.70; 95% CI, –2.73 to 38.15) and optometrists decreasing 4.60% (–$5.76; 95% CI, –9.17 to –2.34) per beneficiary per quarter. Ancillary services decreased 7.56% (–$2.19; 95% CI, 4.19 to –0.22). Intravitreal injection costs increased 25.0% ($20.02; 95% CI, –1.38 to 41.41) with the number increasing 5.10% (1.83; 95% CI, –0.1 to 3.80). There was a 74.09% increase (8.38 injections; 95% CI, 0.01–16.74) in ranibizumab and a 12.91% decrease (–3.40 injections; 95% CI, –6.86 to 0.07) in bevacizumab after acquisition. The event study showed consistent and often statistically significant increases in ranibizumab injections and decreases in bevacizumab injections after acquisition.
Conclusions
Although not all results reached statistical significance, this study suggested that PE acquisition of practices showed little or no overall effect on use or total spending, but increased the number of unique patients seen per optometrist and the use of expensive intravitreal injections.
Private equity (PE) firms increasingly are acquiring ophthalmology practices; little is known of their influence on care use and spending. We studied changes in use and Medicare spending after PE acquisition.
Design
Retrospective cohort study.
Participants
Seven hundred sixty-two clinicians in 123 practices acquired by PE between 2017 and 2018 and 34 807 clinicians in 20 549 never-acquired practices.
Methods
We analyzed Medicare fee-for-service claims (2012–2019) combined with a novel national database of PE acquisitions of ophthalmology practices using a difference-in-differences method within an event study framework to compare changes after a practice was acquired with changes in practices that were not acquired.
Main Outcome Measures
Numbers of beneficiaries seen; intravitreal injections and medications used for injections; and spending on ophthalmologist and optometrist services, ancillary services, and intravitreal injections.
Results
Comparing PE-acquired with nonacquired practices showed a 23.92% increase (n = 4.20 beneficiaries; 95% confidence interval [CI], 1.73–6.67) in beneficiaries seen per PE optometrist per quarter and no change for ophthalmologists, while spending per beneficiary increased 5.06% ($9.66; 95% CI, –2.82 to 22.14). Spending on clinician services decreased 1.62% (–$2.37; 95% CI, –5.78 to 1.04), with ophthalmologist services increasing 5.46% ($17.70; 95% CI, –2.73 to 38.15) and optometrists decreasing 4.60% (–$5.76; 95% CI, –9.17 to –2.34) per beneficiary per quarter. Ancillary services decreased 7.56% (–$2.19; 95% CI, 4.19 to –0.22). Intravitreal injection costs increased 25.0% ($20.02; 95% CI, –1.38 to 41.41) with the number increasing 5.10% (1.83; 95% CI, –0.1 to 3.80). There was a 74.09% increase (8.38 injections; 95% CI, 0.01–16.74) in ranibizumab and a 12.91% decrease (–3.40 injections; 95% CI, –6.86 to 0.07) in bevacizumab after acquisition. The event study showed consistent and often statistically significant increases in ranibizumab injections and decreases in bevacizumab injections after acquisition.
Conclusions
Although not all results reached statistical significance, this study suggested that PE acquisition of practices showed little or no overall effect on use or total spending, but increased the number of unique patients seen per optometrist and the use of expensive intravitreal injections.
19.
Braun, Robert Tyler; Unruh, Mark A; Stevenson, David G; Prigerson, Holly G.; Fernandez, Rahul; Yao, Leah Z; Casalino, Lawrence P.
2023.
Abstract | Links | BibTeX | Tags: Corporatization and Consolidation
@bachelorthesis{nokey,
title = {Changes in Diagnoses and Site of Care for Patients Receiving Hospice Care From Agencies Acquired by Private Equity Firms and Publicly Traded Companies},
author = {Robert Tyler Braun and Mark A Unruh and David G Stevenson and Holly G. Prigerson and Rahul Fernandez and Leah Z Yao and Lawrence P. Casalino},
doi = {10.1001/jamanetworkopen.2023.34582},
year = {2023},
date = {2023-09-05},
urldate = {2023-09-05},
journal = {JAMA Netw Open},
volume = {5},
number = {9},
issue = {6},
abstract = {Importance: Private equity firms and publicly traded companies have been acquiring US hospice agencies; an estimated 16% of US hospice agencies are owned by private equity (PE) firms or publicly traded companies (PTC).
Objective: To examine the association of PE and PTC acquisitions of hospices with Medicare patients' site of care and clinical diagnoses.
Design, setting, and participants: This cohort study of US hospice agencies used a novel national database of acquisitions merged with the Medicare Post-Acute Care and Hospice Public Use File for 2013 to 2020. Changes in sites of care and patient characteristics for hospice agencies acquired by PE or PTCs were compared with changes for patients in nonacquired for-profit hospice agencies.
Exposure: Private equity and publicly traded company acquisitions.
Main outcomes and measures: This study used a difference-in-differences approach within an event-study framework to examine the association of PE and PTC acquisitions of hospice agencies with changes in patient diagnoses and sites of care. Dependent variables were annual hospice-level measures of the Hierarchical Condition Category (HCC) score and proportion of patients diagnosed with cancer or dementia. Sites of care included the proportion of patients receiving hospice care in their personal home, nursing home, or assisted living facility.
Results: A total of 158 hospice agencies acquired by PEs, 250 acquired by PTCs, and 1559 other for-profit hospice agencies were included. Preacquisition, hospice agencies that would later be acquired by PE or PTC served a mean (IQR) 30.1% (12.0%-44.0%) and 29.4% (13.0%-43.0%) of their patients in nursing homes respectively, a greater proportion compared with the 27.1% (8.0%-43.8%) served by for-profit hospices that were never acquired. Agencies acquired by PE between 2014 and 2019 saw a significant relative increase of 5.98% in dementia patients (1.38 percentage points; 95% CI, 0.35-2.40 percentage points; P = .008). In PTC-owned hospices, the proportion of patients receiving care at home increased by 5.26% (2.98 percentage points; 95% CI, 1.46-4.51 percentage points; P < .001), the proportion of dementia patients rose by 13.49% (3.11 percentage points; 95% CI, 2.14-4.09 percentage points; P < .001), and the HCC score decreased by 1.37% (-3.19 percentage points; 95% CI, -5.92 to -0.47 percentage points; P = .02).
Conclusions and relevance: These findings suggest that PE and PTCs select patients and sites of care to maximize profits.},
keywords = {Corporatization and Consolidation},
pubstate = {published},
tppubtype = {bachelorthesis}
}
Importance: Private equity firms and publicly traded companies have been acquiring US hospice agencies; an estimated 16% of US hospice agencies are owned by private equity (PE) firms or publicly traded companies (PTC).
Objective: To examine the association of PE and PTC acquisitions of hospices with Medicare patients' site of care and clinical diagnoses.
Design, setting, and participants: This cohort study of US hospice agencies used a novel national database of acquisitions merged with the Medicare Post-Acute Care and Hospice Public Use File for 2013 to 2020. Changes in sites of care and patient characteristics for hospice agencies acquired by PE or PTCs were compared with changes for patients in nonacquired for-profit hospice agencies.
Exposure: Private equity and publicly traded company acquisitions.
Main outcomes and measures: This study used a difference-in-differences approach within an event-study framework to examine the association of PE and PTC acquisitions of hospice agencies with changes in patient diagnoses and sites of care. Dependent variables were annual hospice-level measures of the Hierarchical Condition Category (HCC) score and proportion of patients diagnosed with cancer or dementia. Sites of care included the proportion of patients receiving hospice care in their personal home, nursing home, or assisted living facility.
Results: A total of 158 hospice agencies acquired by PEs, 250 acquired by PTCs, and 1559 other for-profit hospice agencies were included. Preacquisition, hospice agencies that would later be acquired by PE or PTC served a mean (IQR) 30.1% (12.0%-44.0%) and 29.4% (13.0%-43.0%) of their patients in nursing homes respectively, a greater proportion compared with the 27.1% (8.0%-43.8%) served by for-profit hospices that were never acquired. Agencies acquired by PE between 2014 and 2019 saw a significant relative increase of 5.98% in dementia patients (1.38 percentage points; 95% CI, 0.35-2.40 percentage points; P = .008). In PTC-owned hospices, the proportion of patients receiving care at home increased by 5.26% (2.98 percentage points; 95% CI, 1.46-4.51 percentage points; P < .001), the proportion of dementia patients rose by 13.49% (3.11 percentage points; 95% CI, 2.14-4.09 percentage points; P < .001), and the HCC score decreased by 1.37% (-3.19 percentage points; 95% CI, -5.92 to -0.47 percentage points; P = .02).
Conclusions and relevance: These findings suggest that PE and PTCs select patients and sites of care to maximize profits.
Objective: To examine the association of PE and PTC acquisitions of hospices with Medicare patients' site of care and clinical diagnoses.
Design, setting, and participants: This cohort study of US hospice agencies used a novel national database of acquisitions merged with the Medicare Post-Acute Care and Hospice Public Use File for 2013 to 2020. Changes in sites of care and patient characteristics for hospice agencies acquired by PE or PTCs were compared with changes for patients in nonacquired for-profit hospice agencies.
Exposure: Private equity and publicly traded company acquisitions.
Main outcomes and measures: This study used a difference-in-differences approach within an event-study framework to examine the association of PE and PTC acquisitions of hospice agencies with changes in patient diagnoses and sites of care. Dependent variables were annual hospice-level measures of the Hierarchical Condition Category (HCC) score and proportion of patients diagnosed with cancer or dementia. Sites of care included the proportion of patients receiving hospice care in their personal home, nursing home, or assisted living facility.
Results: A total of 158 hospice agencies acquired by PEs, 250 acquired by PTCs, and 1559 other for-profit hospice agencies were included. Preacquisition, hospice agencies that would later be acquired by PE or PTC served a mean (IQR) 30.1% (12.0%-44.0%) and 29.4% (13.0%-43.0%) of their patients in nursing homes respectively, a greater proportion compared with the 27.1% (8.0%-43.8%) served by for-profit hospices that were never acquired. Agencies acquired by PE between 2014 and 2019 saw a significant relative increase of 5.98% in dementia patients (1.38 percentage points; 95% CI, 0.35-2.40 percentage points; P = .008). In PTC-owned hospices, the proportion of patients receiving care at home increased by 5.26% (2.98 percentage points; 95% CI, 1.46-4.51 percentage points; P < .001), the proportion of dementia patients rose by 13.49% (3.11 percentage points; 95% CI, 2.14-4.09 percentage points; P < .001), and the HCC score decreased by 1.37% (-3.19 percentage points; 95% CI, -5.92 to -0.47 percentage points; P = .02).
Conclusions and relevance: These findings suggest that PE and PTCs select patients and sites of care to maximize profits.
20.
Bond, Amelia M.; Casalino, Lawrence P.; Tai-Seale, Ming; Unruh, Mark Aaron; Zhang, Manyao; Qian, Yuting; Kronick, Richard
Physician Turnover in the United States Journal Article
In: Annals of Internal Medicine, vol. 176, iss. 7, pp. 896-903, 2023.
Abstract | Links | BibTeX | Tags: Medical Professionalism and Physician Well-being
@article{nokey,
title = {Physician Turnover in the United States},
author = {Amelia M. Bond and Lawrence P. Casalino and Ming Tai-Seale and Mark Aaron Unruh and Manyao Zhang and Yuting Qian and Richard Kronick},
doi = {https://doi.org/10.7326/M22-2504},
year = {2023},
date = {2023-07-11},
urldate = {2023-07-11},
journal = {Annals of Internal Medicine},
volume = {176},
issue = {7},
pages = {896-903},
abstract = {Background: Medical groups, health systems, and professional associations are concerned about potential increases in physician turnover, which may affect patient access and quality of care.
Objective: To examine whether turnover has changed over time and whether it is higher for certain types of physicians or practice settings.
Design: The authors developed a novel method using 100% of traditional Medicare billing to create national estimates of turnover. Standardized turnover rates were compared by physician, practice, and patient characteristics.
Setting: Traditional Medicare, 2010 to 2020.
Participants: Physicians billing traditional Medicare.
Measurements: Indicators of physician turnover—physicians who stopped practicing and those who moved from one practice to another—and their sum.
Results: The annual rate of turnover increased from 5.3% to 7.2% between 2010 and 2014, was stable through 2017, and increased modestly in 2018 to 7.6%. Most of the increase from 2010 to 2014 came from physicians who stopped practicing increasing from 1.6% to 3.1%; physicians moving increased modestly from 3.7% to 4.2%. Modest but statistically significant (P < 0.001) differences existed across rurality, physician sex, specialty, and patient characteristics. In the second and third quarters of 2020, quarterly turnover was slightly lower than in the corresponding quarters of 2019.
Limitation: Measurement was based on traditional Medicare claims.
Conclusion: Over the past decade, physician turnover rates have had periods of increase and stability. These early data, covering the first 3 quarters of 2020, give no indication yet of the COVID-19 pandemic increasing turnover, although continued tracking of turnover is warranted. This novel method will enable future monitoring and further investigations into turnover.
Primary Funding Source: The Physicians Foundation Center for the Study of Physician Practice and Leadership.},
keywords = {Medical Professionalism and Physician Well-being},
pubstate = {published},
tppubtype = {article}
}
Background: Medical groups, health systems, and professional associations are concerned about potential increases in physician turnover, which may affect patient access and quality of care.
Objective: To examine whether turnover has changed over time and whether it is higher for certain types of physicians or practice settings.
Design: The authors developed a novel method using 100% of traditional Medicare billing to create national estimates of turnover. Standardized turnover rates were compared by physician, practice, and patient characteristics.
Setting: Traditional Medicare, 2010 to 2020.
Participants: Physicians billing traditional Medicare.
Measurements: Indicators of physician turnover—physicians who stopped practicing and those who moved from one practice to another—and their sum.
Results: The annual rate of turnover increased from 5.3% to 7.2% between 2010 and 2014, was stable through 2017, and increased modestly in 2018 to 7.6%. Most of the increase from 2010 to 2014 came from physicians who stopped practicing increasing from 1.6% to 3.1%; physicians moving increased modestly from 3.7% to 4.2%. Modest but statistically significant (P < 0.001) differences existed across rurality, physician sex, specialty, and patient characteristics. In the second and third quarters of 2020, quarterly turnover was slightly lower than in the corresponding quarters of 2019.
Limitation: Measurement was based on traditional Medicare claims.
Conclusion: Over the past decade, physician turnover rates have had periods of increase and stability. These early data, covering the first 3 quarters of 2020, give no indication yet of the COVID-19 pandemic increasing turnover, although continued tracking of turnover is warranted. This novel method will enable future monitoring and further investigations into turnover.
Primary Funding Source: The Physicians Foundation Center for the Study of Physician Practice and Leadership.
Objective: To examine whether turnover has changed over time and whether it is higher for certain types of physicians or practice settings.
Design: The authors developed a novel method using 100% of traditional Medicare billing to create national estimates of turnover. Standardized turnover rates were compared by physician, practice, and patient characteristics.
Setting: Traditional Medicare, 2010 to 2020.
Participants: Physicians billing traditional Medicare.
Measurements: Indicators of physician turnover—physicians who stopped practicing and those who moved from one practice to another—and their sum.
Results: The annual rate of turnover increased from 5.3% to 7.2% between 2010 and 2014, was stable through 2017, and increased modestly in 2018 to 7.6%. Most of the increase from 2010 to 2014 came from physicians who stopped practicing increasing from 1.6% to 3.1%; physicians moving increased modestly from 3.7% to 4.2%. Modest but statistically significant (P < 0.001) differences existed across rurality, physician sex, specialty, and patient characteristics. In the second and third quarters of 2020, quarterly turnover was slightly lower than in the corresponding quarters of 2019.
Limitation: Measurement was based on traditional Medicare claims.
Conclusion: Over the past decade, physician turnover rates have had periods of increase and stability. These early data, covering the first 3 quarters of 2020, give no indication yet of the COVID-19 pandemic increasing turnover, although continued tracking of turnover is warranted. This novel method will enable future monitoring and further investigations into turnover.
Primary Funding Source: The Physicians Foundation Center for the Study of Physician Practice and Leadership.