Health Policy

BackgroundTo address the growing care demands, many current health system reforms are aiming to strengthen primary healthcare (PHC) services and their accessibility. However, especially larger structural reforms can also influence where PHC services are provided. Following the recent Finnish administrative reform, the new wellbeing services counties are currently centralizing their PHC service networks, resulting in closures of PHC service points. Our aim was to examine the determinants of PHC center unit closure decisions. MethodsHealth center unit closure decisions were systematically extracted from policy documents. Publicly available municipality and county-level register data were utilized, encompassing population characteristics, geographics, as well as service network and reform-related factors. Multilevel logistic regression was conducted to analyze the factors associated with closures in the area of a municipality. ResultsOut of 295 municipalities, 82 were facing health center unit closures, with 45 left without a unit (previously four). A higher number of current (public) health centers (OR: 15.17, CI: 5.51-41.80), a better medical desert index value (OR: 1.90, CI: 1.27-2.83), and the county being a new actor with no previous joint administration (OR: 10.95, CI: 1.15-104.33) were associated with closure decisions. In contrast, greater municipal population growth (OR: 0.21, CI: 0.08-0.53) and a higher number of private clinics (OR: 0.22, CI: 0.05-0.94) were associated with lower odds of closures. ConclusionsThe planned health center unit closures appear reasonably well targeted. Counties with no previous collaboration between municipalities face accumulated service reform needs, leading to more significant changes in their PHC service networks. Similar future structural reforms should consider previous administrative structures, which can influence accumulated local service reform needs, and the current service networks to facilitate the implementation process.

At the beginning of the COVID-19 pandemic, hospitals around the world modified policies for many services, including maternity care, to limit viral transmission. While early decisions were made under significant uncertainty, it is not clear how much consistency there was across jurisdictions, or whether some of these policies inadvertently and disproportionately impacted maternal and infant health for marginalized populations. Using a digital archive database, this study examines how maternity policies evolved during the COVID-19 pandemic across Ontario hospitals, assesses equity implications for marginalized communities, and evaluates the extent to which policy changes aligned with data-driven public health risk assessments. A thematic content analysis of obstetric policy documents on 13 Ontario hospital websites between 2020 and 2023 explores three policy areas with equity implications for maternal care: visitor access, support partner restrictions, and doula care limitations. Using a health equity perspective, findings show a high degree of variability in how the Ontario Ministry of Health policies were implemented both within and across hospitals and raise concerns about equity for marginalized populations, social justice in health, and evidence-informed policy alignment.

BackgroundEmployers in Canada are increasingly offering physician services to their employees, often through third party workplace "enterprise healthcare" platforms. To date however, little work has been done to understand this method of organizing and delivering care. ObjectiveTo understand the nature, extent and implications of enterprise healthcare physician services in Canada. MethodsWe conducted structured internet and database searches to identify enterprise healthcare platforms that provided physician services and their public websites. To answer our research question, We extracted data from company websites and linked company documents as well as information from Mergent Intellect, a web-based application with business data on Canadian companies. ResultsWe identified nine companies offering enterprise physician services to employees in Canada via 11 enterprise software platforms. According to company claims, over four million Canadian employees and their family members have access to enterprise physician services. All platforms offer virtual physician services and five also facilitate in person visits. Ten of the platforms provide primary care services and one offers only addiction medicine services. Four of the platforms offer to communicate and share information with an employees regular primary care provider. Five state they share aggregate or de-identified health data with employers. ConclusionsEnterprise healthcare companies provide millions of Canadian employees and their families with rapid access to virtual physician services and, in some cases, in person care. These services may disrupt continuity of care (care by the same provider over time) and pose risks to employee privacy. As other Canadians do not have access to these services, enterprise healthcare is also introducing two-tiered healthcare across Canada potentially affecting the sustainability of the public healthcare system.

ImportanceAs healthcare costs continue to rise, high-income countries--including Japan--face the urgent task of reducing healthcare spending incurred by low-value care. However, evidence is limited as to which low-value care services contribute most to unnecessary healthcare spending outside of the United States. ObjectiveTo identify which low-value care services contribute the most to unnecessary healthcare spending in Japan. Design, Setting, and ParticipantsThe cross-sectional study of all beneficiaries using a population-based claims database from April 1, 2022, to March 31, 2023, encompassing all age groups, reflecting approximately 2% of the total Japanese population. Main Outcomes and MeasuresWe identified 52 low-value care services based on clinical evidence, and examined their contributions to healthcare spending using two versions of claims-based measures with different sensitivities and specificities (broader and narrower definitions). Each service was categorized into four groups based on its average per-service price: very low (<1,000 Japanese yen [JPY] = 8 US dollars [USD] in 2022), low (1,000-9,999 JPY), medium (10,000-99,999 JPY), or high ([&ge;]100,000 JPY). ResultsAmong 1,923,484 beneficiaries (mean [SD] age 58.6 [23.5] years; 52.7% female), we identified 3.1 million (narrower definition) to 3.7 million (broader definition) episodes of low-value care services (1.6-1.9 per capita), with 36-40% of patients receiving at least one low-value care service. These services accounted for 0.7-1.0% of total healthcare spending, amounting to 207-331 billion JPY (1.7-2.6 billion USD) when extrapolated nationwide with adjustments for age, sex, and region. When applying narrower definitions, over 99% of low-value care episodes involved very-low-cost or low-cost services, which accounted for 67% of unnecessary healthcare spending--far exceeding the 33% attributed to medium-cost or high-cost services. Conclusion and RelevanceOver one in three Japanese individuals received low-value care during 2022-2023, contributing to 0.7-1.0% of total healthcare spending. Among these services, low-cost services contributed to virtually all low-value care utilization and over two-thirds of unnecessary healthcare spending. Compared to focusing solely on high-cost services, targeting the reduction of frequently performed, lower-cost services may be a more effective strategy for reducing wasteful spending. KEY POINTS QuestionWhich low-value care services--low-cost or high-cost--contribute most to unnecessary healthcare spending in Japan? FindingsIn a cross-sectional study of nearly two million beneficiaries examining 52 low-value care services, over one-third received at least one such service during a one-year period, accounting for 0.7-1.0% of total healthcare spending. More than 99% of episodes were very-low- or low-cost services, accounting for over two-thirds of low-value care spending, exceeding spending from medium- and high-cost services. MeaningFocusing on frequently performed, lower-cost services may better reduce wasteful healthcare spending than targeting only high-cost services.

ObjectiveTo quantify waiting time in days for scheduled outpatient specialist consultations and to compare waiting time between standardized and non-standardized access pathways in Ecuadorian public hospitals. MethodsWe analyzed hospital-based survey data from Ecuadorian public hospitals, restricted to adults attending a scheduled outpatient specialist consultation (n = 4,436). Emergency care, unscheduled urgent visits, procedures, and follow-up visits were excluded by design. Access pathway was classified from participants self-report as standardized (institutional or system-based) or non-standardized (informal or non-system-based). Waiting time, defined as the number of days between obtaining the appointment and attending the consultation, was compared using the Mann-Whitney U test. Sociodemographic correlates of non-standardized access were examined using adjusted logistic regression, and adjusted median differences were estimated using quantile regression ({tau} = 0.50). Analyses were stratified into direct-access specialties and referral-required specialties. ResultsNon-standardized access was associated with shorter waiting times than standardized access. In adjusted median regression, non-standardized access was associated with a 3.2-day shorter median waiting time (95% CI -4.6 to -1.8). The difference was larger in direct-access specialties (-15.0 days, 95% CI -15.0 to -6.0) than in referral-required specialties (-5.0 days, 95% CI -5.0 to 0.0). ConclusionAmong patients who attended a scheduled outpatient specialist consultation in Ecuadorian public hospitals, non-standardized access was associated with shorter waiting times, particularly in direct-access specialties. These findings suggest that, within routine outpatient care, parallel access pathways may shape timeliness and warrant greater transparency in appointment allocation and referral coordination.

IntroductionThe global rise in medical interventions during childbirth, such as caesarean sections, has raised concerns regarding their necessity and impact on maternal and neonatal outcomes. Midwifery-led units (MLUs) have demonstrated lower intervention rates and higher maternal satisfaction.This study evaluates the implementation and effects of the first MLU in the Spanish National Health System. MethodsA retrospective cross-sectional trend study and a cohort study were conducted to compare childbirth interventions and outcomes at XX with other hospitals of varying complexities. ResultsThe introduction of the MLU at XX resulted in a significant reduction in caesarean sections, decreasing from 23.5% to 13.5%, and an increase in spontaneous vaginal births, rising from 64.2% to 78.7%. These trends reversed following the MLUs closure in 2022, with caesarean sections increasing to 22.9% and spontaneous births dropping to 69.0%. The MLU served 1286 women, with the majority classified as low-risk pregnancies. Obstetric emergencies in the MLU were low and comparable to those in countries with established MLUs. DiscussionThis study highlights the potential benefits of integrating MLUs into traditionally medicalized healthcare systems to promote physiological childbirth and reduce unnecessary interventions. The positive outcomes achieved at HM are comparable to those in countries with more established MLU practices, reflecting the units commitment to evidence-based care. The increasing interest among women in midwifery-led care indicates a broader demand for supportive, less medicalized childbirth environments. ConclusionsMLU can lead to lower caesarean section rates and higher spontaneous vaginal birth rates, contributing to more positive maternal and neonatal outcomes. However, sustained support and investment in these units are crucial to maintain these benefits. Policymakers and healthcare providers should consider expanding the integration of MLUs within the Spanish National Health System to enhance maternal care quality and align with best practices.

ObjectivesTo determine the clinical and economic impact of a community-based, hybrid model of in-person and virtual care by comparing health-system performance of the rural jurisdiction where this model was implemented with neighbouring jurisdictions without such a model and the broader regional health system. DesignA cross-sectional comparative study. SettingOntario, Canada, with a focus on three largely rural public health units from April 1, 2018, until March 31, 2021. ParticipantsAll residents of Ontario, Canada under the age of 105 eligible for the Ontario Health Insurance Plan (OHIP) during the study period. InterventionsAn innovative, community-based, hybrid model of in-person and virtual care, the Virtual Triage and Assessment Centre (VTAC), was implemented in Renfrew County, Ontario on March 27, 2020. Main outcome measuresPrimary outcome was change in emergency department (ED) visits anywhere in Ontario, secondary outcomes included changes in hospitalizations and health-system costs, using percent changes in mean monthly values of linked health-system administrative data for two years pre-implementation and one year post-implementation. ResultsRenfrew County saw larger declines in ED visits (-34.4%, 95% confidence interval -41.9% to -26.0%) and hospitalizations (-11.1%, 95% confidence interval -19.7% to -1.5%), and slower growth in health-system costs than other rural regions studied. VTAC patients low-acuity ED visits decreased by -32.9%, high-acuity visits increased by 8.2%, and hospitalizations increased by 30.0%. ConclusionAfter implementing VTAC, Renfrew County saw reduced ED visits and hospitalizations and slower health-system cost growth compared to neighbouring rural jurisdictions. VTAC patients experienced reduced unnecessary ED visits and increased appropriate care. Community-based, hybrid models of in-person and virtual care may reduce the burden on emergency and hospital services in rural, remote and underserved regions. Further study is required to evaluate potential for scale and spread. Trial registrationNot applicable. STRENGTHS AND LIMITATIONS OF THE STUDYO_LIThis study uses population-level health administrative data to investigate the empirical effects of a community-based, hybrid model of in-person and virtual care in rural, remote, and underserved communities, where access to comprehensive primary care is insufficient. C_LIO_LIPopulation-level data from administrative datasets were linked using unique encoded identifiers and analyzed at ICES, Ontarios population health data steward. C_LIO_LIThe intervention jurisdiction is compared with two similar adjoining jurisdictions and with the whole Province. C_LIO_LIBecause of the relatively short time period studied -- two years before the intervention and one year post -- it remains to be seen whether the observed differences will persist over time. C_LIO_LIThis studys design does not allow firm inferences about causality; however, the observed changes are in the right temporal sequence and benefit from local comparisons of similar jurisdictions. C_LI

AbstractsO_ST_ABSImportanceC_ST_ABSThe Inflation Reduction Act (IRA) introduced significant reforms to Medicare Part D in 2025, aiming to reduce medication costs for beneficiaries by eliminating the coverage gap ("donut hole") with a $2,000 annual out-of-pocket cap. However, insurers responses to these policy reforms--and their potential implications for medication affordability and access--have not been systematically evaluated. ObjectiveTo assess how Medicare Part D plans adjusted benefit design and formulary structures in response to the IRA and determine the impact of these adjustments on beneficiaries financial responsibilities. Design, Setting, and ParticipantsRetrospective comparative analysis of Medicare Part D plans (Standalone Prescription Drug Plans [PDPs] and Medicare Advantage Prescription Drug [MAPD] plans), comparing plan structure, formulary coverage, utilization management, and cost-sharing details from January 2024 to January 2025. Analyses were conducted using publicly available Centers for Medicare & Medicaid Services (CMS) datasets. Main Outcome(s) and Measure(s)Primary outcomes included changes in annual deductible amounts, cost-sharing structures (co-payment vs co-insurance), formulary coverage and utilization management practices, and patient out-of-pocket costs for GLP-1 medications, including first-fill cost burden. ResultsAcross PDPs, mean annual deductibles significantly increased from $384.7 (95% CI, 369.2-400.1) to $454.0 (95% CI, 432.9-475.1); MAPD plans showed a greater increase from $98.7 (95% CI, 93.6-103.8) to $249.0 (95% CI, 241.4-256.6). In MAPD plans, co-insurance style coverage utilization drastically increased for tier 3 medications (2024: 6.3%, 2025: 38.1%). Specifically, for GLP-1s, while overall coverage decreased, preferred drugs like Ozempic and Mounjaro experienced expanded coverage. However, first-fill out-of-pocket expenses increased substantially due to higher deductibles and increased costs associated with co-insurance style coverage. First-fill costs exceeding $600 rose from 40%-45% (2024) to over 80% (2025) in PDPs and from less than 1% to approximately 13% in MAPD plans. Conclusions and RelevanceMedicare Part D plans in 2025 were strategically designed to increase beneficiaries financial responsibilities via higher deductibles, increased co-insurance cost-sharing, and restricted formulary coverage. While overall annual patient medication cost burdens will decrease, the cost of filling each medication will increase, which may negatively impact medication access and adherence. Key PointsO_ST_ABSQuestionC_ST_ABSHow did 2025 Medicare Part D plans respond and adapt to new IRA policies, and how is this affecting medication affordability and access? FindingsPart D plans have adopted higher deductibles, shifted from co-payment to co-insurance, and limited formulary coverage, which has increased beneficiaries financial responsibility and negatively impacted medication access. MeaningAlthough IRA provisions may reduce patients annual medication out-of-pocket costs, Part D plans are adopting new strategies that increase patients financial challenges.

Delayed discharges of patients from hospitals, also known as "bed-blocking" is a long standing policy concern. Such delays can increase hospital treatment costs and may also lead to poorer patient health and experience. Prior research indicates that external factors, such as, greater availability and better affordability of long term care associated with lower delays. Using theories from Economics, this study examines the role of within-hospital factors, namely, staff well-being in alleviating hospital delayed days. We use a new panel database of delays in all English hospital trusts from 2011/12 to 2014/15. Employing longitudinal count data models, the paper finds that staff well-being is associated with lower hospital delayed discharges controlling for long-term factors and management quality. The findings are robust to alternative methods and measures of delayed discharges.

IntroductionTelehealth expanded rapidly following the COVID-19 pandemic and has become an integral part of healthcare delivery. However, concerns remain that increased telehealth availability may contribute to higher overall healthcare utilization and spending. To assess telehealths impact on outpatient evaluation and management (E&M) visit volume, we compared overall E&M utilization before and after the pandemic across specialties with varying levels of telehealth use. MethodsWe analyzed 100% Medicare Fee-For-Service (FFS) claims to compare monthly outpatient E&M visit rates between two periods: pre-pandemic (January 2019-February 2020) and post-pandemic (January 2021-June 2024). Specialties were categorized by telehealth use as high (behavioral health), medium (primary care), and low (orthopedic surgery). A difference-in-differences (DID) analysis was used to assess changes in visit volume associated with telehealth. ResultsPrior to the pandemic, telehealth accounted for just 0.1% of monthly E&M visits but surged to 41.0% in April 2020 before stabilizing between 5.7% and 7.0% in 2023-2024. The average monthly E&M visit rate per 1,000 FFS beneficiaries was 906.8 pre-pandemic and 918.6 post-pandemic. In the post-pandemic period, telehealth comprised 1.2% of E&M visits in low-use specialties, 8.4% in medium-use specialties, and 43.8% in high-use specialties. Compared to the expected trend based on the low telehealth-use specialty, high and medium telehealth-use specialties experienced a 4.1% and 7.2% relative decline in overall E&M visits, respectively, in the post-pandemic period. ConclusionFollowing an initial surge, telehealth use stabilized in 2021 and beyond. Overall outpatient utilization remained stable post-pandemic, and increased telehealth adoption was not associated with a rise in total outpatient E&M visits. These findings suggest that broad telehealth adoption has not led to increased healthcare utilization among Medicare FFS beneficiaries.

ObjectiveTo develop and validate a logistic regression model for analyzing the probability of caesarean section births, adjusted for clinical complexity, across public hospitals in Catalonia, and to identify deviations from expected caesarian section rates for benchmarking and quality improvement. MethodsThis retrospective cohort study analyzed data from the Catalan National Health Systems Minimum Basic Data Set (CMBD-AH), including all deliveries in public hospitals from January 2018 to June 2024. A logistic regression model was constructed using maternal and obstetric factors such as age, obstetric history, and clinical conditions. The model was validated through calibration plots and receiver operating characteristic (ROC) curve analysis, achieving an area under the curve (AUC) of 0.803. ResultsThe analysis revealed variability in observed-to-expected caesarean section ratios across hospital complexity levels. Level III hospitals aligned closely with expected rates, reflecting adherence to clinical standards for high-complexity cases. Level I hospitals demonstrated significant variability, with 59.1% performing more cesareans than expected; smaller hospitals with fewer than 1,000 births exhibited the greatest deviation. The model highlighted both underperforming and overperforming institutions, offering actionable insights for resource allocation and policy interventions. ConclusionsThe logistic regression model provides a robust framework for evaluating caesarean section practices, enabling fair comparisons between hospitals by adjusting for clinical complexity. It supports the identification of non-clinical factors influencing cesarean practices and offers a critical tool for quality improvement and optimizing maternal healthcare within Catalonias public health system.

BackgroundHospital at home (HaH), either admission avoidance (AA) or early supported discharge (ESD), was increasingly implemented in Catalonia (7.7 M, Spain) for selected patients, achieving regional adoption within the 2011-2015 Health Plan. This study aimed to assess population-wide HaH outcomes over five years (2015-2019) in a consolidated regional HaH program and provide context-independent recommendations for service quality assurance. MethodsA mixed-methods approach was adopted, combining population-based retrospective analyses of registry information with qualitative research. AA and ESD were separately compared with conventional hospitalization groups using propensity score matching techniques. In the analysis, we evaluated the 12-month period before the acute episode, the admission, and use of healthcare resources at 30 and 90 days after discharge. A panel of experts discussed the results and provided recommendations for monitoring HaH services. ResultsThe adoption of AA steadily increased from 5,185 to 8,086 episodes/year (total episodes 31,901; mean age 73 (SD 17) years; 79% high-risk patients), whereas ESD remained stable over the study period, averaging 5,329 episodes per year (total episodes 26,646; mean age 68 (SD 16) years; 71% high-risk patients). Mortality rates were similar in HaH and conventional hospitalization within the episode (AA: 0.31% vs. 0.45%; ESD: 0.18% vs. 0.45%) and at 30-days (AA: 3.94% vs. 3.24%; ESD: 4.50% vs. 4.07%). Likewise, the frequency of patients requiring hospital re-admissions or ER visits 30 days after discharge was similar in HaH (AA and ESD) and the corresponding controls. The 27 healthcare providers assessed showed high variability in patients age, multimorbidity, severity of episodes, recurrences, and length of stay of AA episodes. Recommendations aiming at enhancing service delivery were produced. ConclusionsBesides confirming safety and value generation of AA, we found that this service is delivered in a case-mix of diferent scenarios, encouraging provider-profiled monitoring of the service, particularly for ESD modalities. Impact statementWe certify that this work is confirmatory of Admission Avoidance (AA) as a value-based service by analyzing, with a population-based approach, a five-year period after regional adoption of AA in Catalonia. The research indicates the need for implementing quality assurance programs after service adoption and provides clear insights on how shape quality monitoring. The current study outcomes add novel knowledge to previous reports in the field, such as: O_LILeff B, DeCherrie L v., Montalto M, Levine DM. A research agenda for hospital at home. J Am Geriatr Soc. 2022;70(4):1060-1069. doi:10.1111/JGS.17715 C_LIO_LILevine DM, Ouchi K, Blanchfield B, et al. Hospital-Level Care at Home for Acutely Ill Adults: A Randomized Controlled Trial. Ann Intern Med. 2020;172(2):77-85. doi:10.7326/M19-0600 C_LIO_LIMontalto M, McElduff P, Hardy K. Home ward-bound: features of hospital in the home use by major Australian hospitals, 2011-2017. Med J Aust. 2020;213(1):22-27. doi:10.5694/mja2.50599 C_LIO_LIHecimovic A, Matijasevic V, Frost SA. Characteristics and outcomes of patients receiving Hospital at Home Services in the South-West of Sydney. BMC Health Services Research. 2020;20(1):1090. doi:10.1186/s12913-020-05941-9 C_LIO_LILEONG MQ ET AL. Comparison of Hospital-at-Home models: a systematic review of reviews. BMJ Open. 2021;11:43285. doi:10.1136/bmjopen-2020-043285 C_LI The current manuscript covers relevant knowledge gaps well-identified in the nine dimensions for future research in the field of hospital at home reported by Leff B et al, 2022. Moreover, the population-based approach of the research provides a valuable approach for quality assurance of the different service modalities. O_TEXTBOXKey PointsO_LILarge scale adoption of Admission Avoidance shows value generation in real-world settings C_LIO_LIImplementation of continuous quality assurance monitoring after service adoption is highly recommended. C_LI Why does this paper matter?The population-based approach of the study design allows identification of key elements for service improvement after consolidated regional adoption of Hospital at Home Key strengths of the research are: i) demonstration of healthcare value generation of AA in large scale adoption of the service; and ii) generation of insightful recommendations for enhanced service delivery and continuous quality monitoring. C_TEXTBOX

IntroductionAt the start of the COVID-19 public health emergency, the federal government made temporary Medicare policy changes to expand telehealth coverage, resulting in a surge in telehealth use. As federal and state policymakers currently consider permanent telehealth policy options, it is important to understand the trends in telehealth use during 2021 and whether telehealth has led to an increase in the overall volume of healthcare services. MethodsOur analysis was conducted using Part B claims for 100% of Medicare fee-for-service beneficiaries. We identified all outpatient evaluation and management (E&M) services received by beneficiaries from January 1, 2019 through December 31, 2021. We then calculated the monthly proportion of outpatient E&M services that were performed in-person and through telehealth. ResultsThe total number of all outpatient E&M services was 289.0 million in 2019, 255.2 million in 2020 (11.7% lower than 2019), and 260.7 million in 2021 (9.8% lower than 2019). Monthly telehealth services peaked at 7.2 million (or 50.7% of monthly E&M services) in April 2020, followed by a slow decline through the end of 2021. During the second half of 2021, telehealth services made up 8.5-9.5% of monthly E&M services. ConclusionFrom April 2020 through December 2021, the monthly volume of telehealth services slowly declined and has plateaued between 8.5-9.5% of all outpatient E&M services received by Medicare fee-for-service beneficiaries. Importantly, the total volume of outpatient E&M services was lower in 2020 and 2021, suggesting that the COVID-19 telehealth flexibilities have not increased the overall volume of outpatient E&M services received by Medicare beneficiaries. These findings should mitigate some concerns about the impact of telehealth on overall healthcare utilization. At the start of the COVID-19 public health emergency, the federal government made temporary Medicare policy changes to expand telehealth coverage, resulting in a surge in telehealth use.1,2 While telehealth was a necessary substitute for in-person care during first few months of the pandemic, there was a decline in the use of telehealth during the second half of 2020.3 As federal and state policymakers currently consider permanent telehealth policy options, it is important to understand the trends in telehealth use during 2021 and whether telehealth has led to an increase in the overall volume of healthcare services.

BackgroundThe 340B Drug Pricing Program was established to expand access to care for low-income and uninsured patients by allowing safety-net hospitals and clinics to purchase outpatient drugs at discounted prices. Over time, the program has expanded substantially, raising questions about whether participating hospitals are meeting the programs intended objectives. MethodsUsing 2023 hospital financial data from the RAND Corporation, we conducted cross-sectional descriptive comparisons of 340B and non-340B hospitals nationwide. Key measures included charity care as a percentage of operating expenses, Medicaid admissions as a share of hospital days, uncompensated care, and costs associated with uninsured patients approved for charity care. Subgroup analyses also examined the performance of Disproportionate Share Hospitals (DSH), Critical Access Hospitals (CAH), Rural Referral Centers (RRC), Sole Community Hospitals (SCH), and National Cancer Institute (NCI) designated hospitals. ResultsAmong 3,999 hospitals analyzed, 340B hospitals provided, on average, lower levels of charity care than non-340B hospitals (2.16% vs. 2.82% of operating expenses) and lower costs of charity care for uninsured patients (1.60% vs. 2.26%). However, 340B hospitals served a higher proportion of Medicaid patients (19.69% vs. 17.76%). Substantial variation was observed across 340B subcategories: DSH hospitals reported the highest Medicaid utilization, while CAH hospitals reported the lowest levels of charity care and Medicaid days. ConclusionsParticipation in the 340B program does not uniformly correlate with greater provision of charity care or uncompensated care. These findings suggest a misalignment between program intent and outcomes and support the need for greater transparency, standardized eligibility criteria, and minimum charity care requirements to ensure that 340B savings directly benefit underserved populations.

Continuing National Health Service Health Care (CHC) is a package of care for adults with significant primary health care needs who live in England or Wales. Currently, direct payments are not available for individuals receiving CHC in Wales. In contrast, in England, individuals in receipt of CHC can access direct payments as part of a broader system of Personal Health Budgets (PHBs), which offer choice and control over how their care is delivered. The Health and Social Care (Wales) Act 2025 includes provisions enabling the introduction of direct payments for CHC in Wales, with implementation anticipated in 2026, subject to the development of supporting regulations and guidance This review seeks to explore: what approaches have been used to implement direct payments within health systems, and how effective these approaches are in supporting personalisation, governance, and equitable access to care? Searches were conducted on bibliographic databases from 2012 onwards to build upon previous work. Important pre-2012 grey literature evidence was also considered. The review included evidence published from 2010 to 2023. The findings presented are based on the 8 review articles and 16 organisational reports, some of which cover both health and social care. The literature lacks clear definitions and consistent use of the terms related to direct payments and Personal Health Budgets (PHBs), often blurring the distinctions between different approaches. Where possible, findings have been drawn from the broader PHB literature, with relevant sections highlighted that directly address the implementation of direct payments. Many of the key elements for the successful implementation of direct payments are similar across the different models of PHB implementation and include: Robust support and referral systems, clear and accessible information for recipients (patients and families), comprehensive training and guidance for staff involved in implementation to enhance knowledge and attitudes. Policymakers should account for an initial adjustment period when assessing the impact of direct payments, as users and carers, as well as NHS staff, get used to any new arrangements and processes. Researchers should carefully consider the timing of data collection in evaluations of direct payments, as early-stage data may disproportionately reflect implementation challenges rather than long-term outcomes. Longer-term follow-up (minimum of nine months) is essential to capture the full impact of personalised care, allowing users time to adjust, build confidence, and develop sustainable routines that reflect the intended benefits. Funding statementThe authors and their Institutions were funded for this work by the Health and Care Research Wales Evidence Centre, itself funded by Health and Care Research Wales on behalf of Welsh Government.

BackgroundHealthcare fragmentation among adults with multiple chronic conditions (MCC) may drive inefficient care and increased costs, yet little is known about this relationship at the national level. ObjectiveTo examine the association between healthcare utilization fragmentation and total healthcare costs among US adults with multiple chronic conditions, and assess how this relationship varies by insurance type. MethodsCross-sectional analysis of 21,876 adults from the 2020 Medical Expenditure Panel Survey (MEPS). I measured healthcare fragmentation using a composite score based on utilization across multiple provider types and settings. Multiple chronic conditions were defined as [&ge;]3 diagnosed conditions. I used surveyweighted regression models to examine associations between fragmentation, MCC status, and total healthcare expenditures, controlling for demographics, socioeconomic status, and insurance type. ResultsThe sample represented 256 million US adults, with 44.7% (SE: 0.6%) having multiple chronic conditions. Adults with MCC had significantly higher healthcare costs than those without MCC (mean: $13,847 vs. $2,145, respectively). Healthcare fragmentation was associated with dramatic cost increases: expenditures ranged from $909 for no fragmentation to $34,956 for high fragmentation. In adjusted models, MCC was associated with a 167% increase in healthcare costs, while each unit increase in fragmentation score was associated with a 784% cost increase. High fragmentation affected 57.9% of the adult population. ConclusionsHealthcare fragmentation is strongly associated with substantially higher costs, particularly among adults with multiple chronic conditions. These findings suggest that care coordination interventions could yield significant cost savings while potentially improving quality of care.

IntroductionNewfoundland and Labrador (NL) faces persistent difficulty attaching its residents to primary care. We undertook a stock and flow analysis to represent how inflows and outflows of family physicians (FPs) shape effective capacity and to provide a reconciled estimate of FP supply for 2024. This approach clarifies drivers of change, exposes intervention points, and supports timely planning. MethodsWe assembled a multi-year headcount series and linked it to CIHIs "entering/leaving direct care" flows, harmonizing definitions and time frames across sources. We compared observed year-to-year stock change with net flows to identify timing and classification gaps. Stakeholder consultations informed key parameters (graduates and retention, internationally trained entrants, migration, retirement, and scope shift). Because confirmations are released with a lag, we produced a reconciled 2024 estimate using the CIHI headcount as baseline and these validated inputs. FindingsFP headcount changed from 680 (2014) to 666 (2023) (-2.1%) after peaking at 728 (2017); the ratio fell from 129 to 124 per 100,000 population. The workforce became more urban (rural 255[-&gt;]203; urban 424[-&gt;]460) and more Canada-trained (417[-&gt;]466) while foreign trained decreased (261[-&gt;]199). Net interprovincial migration averaged -24/year, with pronounced losses in 2019 (-57) and 2022 (-42). CIHI entry-exit data point to marked volatility in the FP workforce: entries/exits were 110/96 (2019), 62/88 (2020), and 71/117 (2021), with residuals versus stock change indicating definitional/timing differences. The 2024 reconciliation yielded {approx}658 FPs (net -8.5 from 2023), {approx}507 FTE at 0.77 FTE/head, and {approx}122 per 100,000 population. ConclusionInflows from local graduates and IMGs did not fully offset exits from migration, retirement, and scope/burnout in 2024. Recruitment alone is unlikely to close access gaps; retention-first strategies, scaleup of team-based care with role optimization, targeted rural supports, and routine monitoring of flows are needed to stabilize and grow effective primary care capacity in NL.

As telehealth is being integrated into a regularly functioning system, policy makers have been adding some restrictions related to its use (e.g. modalities and pre-existing in-person relationship rules). We explored how the new policies impacted the levels of use across telehealth modalities and if the impact varied across sociodemographic and chronic condition groups of patients. This is a population-based repeated cross-sectional study examining all outpatient visits in Ontario, Canada on a weekly basis from the week of January 1st, 2018 until the week of December 25th, 2023. We used linked health administrative databases of health services provided to all Ontario residents who are insured through the Ontario Health Insurance Plan (OHIP). We examined the total number of visits and the rates of in-person and telehealth visits per 1000 persons per week. Across Ontario, there were 115 046 536 telehealth visits during the study time period (26.4% of all ambulatory care). There was a 6.7% reduction in telehealth and a 10% reduction in the number of physicians using telehealth at the beginning of December 2022 when the new policies were introduced. This was in the absence of a reduction of total ambulatory visits. The impact varied across medical specialties, patient age groups, rurality and chronic conditions, but seemingly not across sex or income quintiles. The use of video increased slightly over the study period with 1 in 4 telehealth visits occurring over video. While the policy changes led to an overall reduction in telehealth use, the total ambulatory visits did not change, suggesting a shift of care from virtual to in-person. The adoption of video increased, but future studies should focus on exploring whether there are clear benefits of using video over telephone, as certain groups of patients may be impacted more than others. Author SummaryAs healthcare systems returned to normal functioning after the pandemic, rules around the use of telehealth (use of telephone and video to provide care) changed. For example, in Ontario, Canada, physicians were paid on par for video visits as in-person visits, but telephone visits were paid at 85% of the rate. In addition, the government introduced requirements related to whether a patient has been seen in-person by a physician within the last two years prior to a telehealth visit. Our study explored the impact of these changes using physician billing data. Overall, there was a 6.7% reduction in telehealth and a 10% reduction in the number of physicians using telehealth when the new policies were introduced in Dec, 2022. The impact varied across medical specialties, patient age groups, rurality and chronic conditions, but seemingly not across sex or income quintiles. Overall outpatient visits were not impacted, suggesting that care shifted back to in-person. The majority of telehealth still occurred over telephone, despite a slight increase in the use of video after the policies were introduced.

BackgroundPrimary healthcare has emerged as a powerful global concept, but little attention has been directed towards the pivotal role of the healthcare workforce and the diverse institutional setting in which they work. This study aims to bridge the gap between the primary healthcare policy and the ongoing healthcare workforce crisis debate by introducing a health system and governance approach to identify transformative capacities in health system contexts. MethodsA qualitative comparative methodology was employed, and a rapid assessment of the primary healthcare workforce was conducted across nine countries: Denmark, Germany, Kazakhstan, Netherlands, Portugal, Romania, Serbia, Switzerland, and the United Kingdom/ England. ResultsOur findings reveal both convergence and pronounced diversity across the healthcare systems, with none fully aligning with the ideal attributes of primary healthcare suggested by WHO. However, across all categories, Denmark, the Netherlands, and to a lesser extent Kazakhstan, depict closer alignment to this model than the other countries. Workforce composition and skill-mix vary strongly, while disparities persist in education and data availability, particularly within Social Health Insurance systems. Policy responses and interventions span governance, organisational, and professional realms, although with weaknesses in the implementation of policies and a systematic lack of data and evaluation. The WHO primary healthcare model only marginally informs policy decisions, with the exception being in Kazakhstan. ConclusionWe conclude that aligning primary healthcare and workforce considerations within the broader health system context may help move the debate forward and build governance capacities to improve resilience in both areas.

ImportanceAmerican maternal and neonatal mortality rates are the worst of the worlds high-income countries. These rates are particularly low among patients of color, who have higher Cesarean delivery rates (CDR), higher healthcare costs, and poorer outcomes than White patients. However, common economic analyses do not address interlinked issues and therefore underestimate both the hidden causes of health inequities and the resultant costs to taxpayers. We have therefore designed a more comprehensive health economic model and metric (DEVELOP) that incorporates population health, equity, and economic integration. Design & MeasuresThe DEVELOP model, a childbirth-specific model of the societal economic gain or loss related to healthcare outcomes, incorporates an individuals long-term economic contributions into its calculations of economic benefits. We first used our model to estimate fiscal outcomes if each states CDR for Black patients was lowered to that of White patients. Second, we calculated the costs of "excess" CDR and mortalities among Black patients. Third, we incorporated the additional long-term economic contributions of mothers and their children. ResultsIn the U.S., maternal and neonatal mortality rates and associated costs were higher for Black patients than White patients, and states with the lowest per capita health expenditures showed worse maternal outcomes and higher continuing costs. If the Black patient CDR were reduced to the White patient CDR, taxpayer-funded healthcare programs would save $263 million annually. Reducing the Black patient MMR would improve economic output by $224 million per year, and reducing the Black patient NMR would save $3.1 billion per year, for a combined economic improvement of $3.3 billion annually. Conclusions and RelevanceThe costs of improved prenatal care should be reconceptualized as investments for future economic growth rather than as short-term burdens. Policies blocking reasonable investments in health equity are counterproductive.