Health Policy

Improving primary care is a long-standing strategy to constrain health care spending. Yet, evaluations of primary care models focused on payment reform have shown minimal effects on total cost of care. We report the results from a large-scale, real-world evaluation of an advanced primary care model that restructures access through same-day and next-day appointments, on-demand video visits, asynchronous clinician messaging, and extended hours. Using a stacked-cohort difference-in-differences design with entropy balancing and inverse probability of censoring weighting, we analyzed multi-payer claims covering April 2022 through March 2025. Advanced primary care use was associated with an 8.6% reduction in total cost of care (-$729 per patient per year; P = 0.004), driven by lower specialist cost (-$939/year; P < 0.001) and, to a lesser degree, by reductions in inpatient (-$134/year; P < 0.001), urgent care (-$70/year; P < 0.001), and emergency department cost (-$16/year; P = 0.02), partially offset by higher primary care cost (+$350/year; P < 0.001). The specialist reduction was concentrated in knowledge-based consultative encounters (-$663/year; P < 0.001), while procedural specialist cost was largely unchanged (-$276/year; P = 0.09). Cost differences emerged in the first post-index month. These findings suggest that advanced primary care may reduce total health care spending, with observed savings driven primarily by lower spending on consultative specialty care.

Strong primary healthcare (PHC) is associated with lower costs and better population health outcomes when supported by appropriate financing. Costing analysis enables evidenced-based decisions for estimating budgets for PHC and defining provider payments. In 2021, a project supported by the World Health Organization was launched in Ukraine to collect cost data from 100 PHC providers. The objective was to assess costs for delivering services within the state-funded benefits package, with the aim of informing tariff-setting, and assessing budget need. This study used statistical analysis on the collected cost data. We applied multivariable linear regression (MLR) to assess variation in cost-per-person across locality (rural vs. urban) and ownership type (public vs. private) of the providers, after adjusting for confounders. The mean (standard deviation) cost-per-person across the sample providers was 45.46 (18.46) USD. MLR analysis showed that rural providers had a higher cost-per-person of 6.70 USD (95% CI: 1.54, 11.85) compared to urban providers, after adjusting for confounding (p=0.011). We also found strong evidence that private providers had a lower cost-per-person of 36.15 USD (95% CI: -41.82,-30.48) compared to public providers, after adjusting for confounding (p<0.001). Although our findings do not capture the impact of the Russian hostile invasion of Ukraine, they still provide valuable insights for policy discussions within Ukraine and for other nations examining PHC financing reforms. Our findings align with international evidence suggesting that rural providers incur higher costs, supporting the need to adjust capitation payments for providers in these areas. Ownership type also affects costs, potentially reflecting differences in quality standards between public and private providers. These differences allow private providers to opportunistically reduce costs by limiting staff numbers and optimizing facility size to maximize profits. To ensure equitable access to high-quality PHC, uniform service delivery standards should be applied to all PHC providers, regardless of ownership type.

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.

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.

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.

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

Abstract Objective To describe variation in hospital costs among children with different combinations of health conditions, special educational needs or disability (SEND) and children social care (CSC) indicators. Study Setting and Design This cross-sectional study used regression analysis to test whether two-way and three-way interactions of cross-public sector service use (health, education and social care) are associated with higher hospital costs in England. Data Sources and Analytic Sample Hospital care costs between April 2022 and March 2023 for the 8.9 million children aged 5-18 years were obtained from linked administrative hospital, education or social care data in the ECHILD database. Children were classified into eight categories based on combinations of indicators of chronic health conditions, SEND or CSC. Principal Findings Over one-third (35.4%) of children had some hospital costs during the year. Average costs were 317GBP for all children and 895GBP for children with non-zero hospital costs. By age 18, few children had no indicator in any sector (35.1% of boys, 43.7% of girls) and indicators in all three sectors were not rare (7.1% of boys, 6.2% of girls). At age 5, children with indicators recorded in all three sectors had the highest hospital costs (2,952GBP for boys and 3,674GBP for girls). At age 18, males and females with indicators in all three sectors accounted for 21% and 23% of hospital costs, respectively. SEND and social care indicators without chronic health conditions were associated with only slightly higher hospital costs. Hospital costs were much higher for children with SEND if they also had a chronic health condition. Hospital costs were only higher for children with social care if they also had both a chronic health condition and SEND. Conclusions. Taking account of additional support from non-health sectors is important for understanding health sector costs. The compounding associations between use of other public sectors on health sector costs indicates scope for targeting of integrated care.

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.

BackgroundGermanys Hospital Care Improvement Act (Krankenhausversorgungsverbesserungsgesetz, KHVVG) establishes 65 hospital service groups (Leistungsgruppen, LGs) with codified structural prerequisites, creating a directed dependency network. It remains unclear whether this regulatory structure appropriately reflects the economic importance of different services, particularly for specialties serving aging populations. MethodsWe modeled KHVVG dependencies as a directed network and calculated centrality metrics for all 65 LGs. Using elastic net regression, we related network position to LG-specific revenue data (2021) as a proxy for real-world service importance. Residuals between actual and network-predicted revenue quantified structural-fiscal alignment. We compared three policy scenarios: baseline KHVVG structure, KHAG reform (eliminating infectious diseases and emergency medicine service groups), and a hypothetical GBA scenario (adding geriatrics as mandatory prerequisite for hip replacement services). ResultsThe regression model explained 56.6% of revenue variance (R{superscript 2}=0.566). Enablement index ({beta}=+0.38) and weighted in-degree ({beta}=-0.84) were primary predictors. Twenty-one LGs (35.6%) showed good alignment (|residual| <0.5 log units), including high-revenue services such as general internal medicine ({euro}9.8B, residual +0.03) and general surgery ({euro}12.1B, residual -0.06). Geriatrics (LG56) exhibited the largest positive residual (+2.24 log units), with actual revenue of {euro}1.84B versus network-predicted {euro}195M--a 9.4-fold gap. The GBA scenario reduced geriatrics residual to +1.52 (-0.72 change, 32% improvement) by transforming it from pure sink node to gateway node. The KHAG scenario produced negligible change (-0.002). ConclusionsNetwork analysis reveals systematic structural-fiscal misalignment for geriatrics despite high service utilization. Strategic prerequisite placement achieves substantially greater alignment improvement than service group elimination. These findings demonstrate a quantitative approach for evaluating how regulatory frameworks recognize service importance, with potential implications for hospital planning in aging populations. HighlightsO_LINetwork analysis quantifies structural-fiscal alignment in German hospital reform C_LIO_LI35.6% of service groups show good alignment between network position and revenue C_LIO_LIGeriatrics shows mathematical 9.4-fold gap: {euro}1.84B actual vs. {euro}195M predicted revenue C_LIO_LIStrategic prerequisite addition reduces alignment gap by 32% (in network-based predictions) C_LIO_LIMethod provides generalizable framework for evaluating health policy reforms in terms of network metrics C_LI

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.

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

IntroductionWe aim to examine whether state-level telehealth policies in 2020 were associated with a reduction in the urban-rural disparity in telehealth utilization. MethodA multilevel model was used to assess state actions impact on urban-rural differences in healthcare utilization. We used the percentage of Medicare Fee-for-Service beneficiaries receiving any telehealth services (measured by county level) in 2020 as the dependent variable. We examined the following state-level policies as key independent variables at the state level: 1) telehealth coverage parity requirement for payers; 2) recognizing a call from patients address as the originating site of telehealth visit; 3) mandating the coverage of audio-only telehealth visits. ResultsBoth mandating the coverage of audio-only visits and telehealth coverage parity requirement were significantly associated with higher level of telehealth utilization. For audio-only reimbursement mandate and telehealth coverage parity requirement, the interaction between the state policy and the countys rurality was associated with a significant increase in telehealth utilization rate, whereas the interaction between the states waiver for the requirement of originating site and the countys rurality was negatively associated with telehealth utilization rate. ConclusionThe audio-only telecare reimbursement mandate and telehealth payment parity could help close the urban-rural gap in telehealth utilization.

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.

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.

Health visiting is England's universal home visiting programme for families with children under five and a key pillar of early intervention policy. Since the 2015 devolution of commissioning to Local Authorities (LAs), the service has faced sustained financial and workforce pressures, yet there is limited systematic evidence on whether resources and delivery have evolved differentially across areas and along the deprivation gradient. Using new Freedom of Information (FOI) data, we estimate how health visiting inputs (spending and workforce) and mandated contact delivery vary in levels and trajectories by baseline deprivation. FOI requests covered 147 English LAs (four pairs submitted joint returns), providing annual 2016-2021 Full-Time Equivalent (FTE) data on Health Visitors (HVs) and Clinical Skill Mix Staff (CSMS), which we link to DHSC Health Visitor Service Delivery Metrics reporting completion of the five mandated 0-5 reviews (New Birth Visits, 6-8 week reviews, 12-month reviews, 2-2.5 year reviews, and 2-2.5 year reviews completed with ASQ-3) and to LA revenue outturn expenditure on mandated and non-mandated 0-5 public health services (real-terms total and per child under five). Between 2016 and 2021, HV FTE fell by around one-fifth while CSMS expanded by roughly one-third, consistent with an overall contraction and a shift toward lower-band staff. To test whether these changes map onto underlying disadvantage, we stratify LAs into tertiles of baseline deprivation using the 2015 Income Deprivation Affecting Children Index (IDACI) and implement a three-part empirical strategy: (i) plotting tertile means over time, (ii) testing within-year cross-sectional differences using parametric and non-parametric methods with pairwise comparisons, and (iii) estimating LA fixed-effects regressions with Year x IDACI interactions under both a flexible year-by-year specification and a parsimonious linear-trend specification to assess differential trajectories. We find persistent cross-sectional gradients in per-child spending that are broadly progressive (more deprived LAs spend more per child on both mandated and non-mandated 0-5 services), while fixed-effects models show little evidence that spending trajectories differ systematically by deprivation. Workforce trends are more uneven: HV FTE declines more slowly and CSMS FTE grows more slowly in more deprived LAs in the linear-trend specification, while per-child HV trajectories show no differential trends. Despite these input differences, completion of mandated contacts is relatively stable across the deprivation gradient; the only consistent differential trend is faster improvement in the 6-8 week review in more deprived areas. Meanwhile, caseload pressure rises, increasing most sharply in the most deprived LAs in the pre-pandemic years, suggesting that completion-based performance measures may mask heterogeneities in service capacity and intensity. Finally, we quantify the resources required to restore recommended caseloads, implying the need for approximately 3,100 additional FTE staff and around 120 million GBP annually (plus training costs).

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.

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.