Nevin Manimala

Health Aff (Millwood). 2025 Oct;44(10):1307-1316. doi: 10.1377/hlthaff.2025.00375.

ABSTRACT

Many Latino immigrants avoid public benefits because of fears about their immigration status or that of family members, which is heightened by anti-immigration rhetoric. This study used data from the Latino Youth Health Study and the 2021-22 California Health Interview Survey to examine decisions not to apply for noncash public benefits, such as Medicaid, food assistance, and housing subsidies, as well as safety perceptions among income-eligible Latino families in California. We also analyzed differences by parental citizenship and household language. Compared to families with two US citizen parents, families with one or both noncitizen parents were more likely (by 38.4 and 46.7 percentage points, respectively) to avoid applying for benefits because of immigration-related concerns, and such families were also more likely to fear deportation for themselves or a family member or close friend. Spanish-only and bilingual households showed similar patterns. These findings underscore the need for accurate information on public benefit eligibility and immigration policies to ensure that immigrant families can access health care and resources to which they are legally entitled.

PMID:41052391 | DOI:10.1377/hlthaff.2025.00375

Health Aff (Millwood). 2025 Oct;44(10):1291-1297. doi: 10.1377/hlthaff.2025.00297.

ABSTRACT

Site neutrality in payment practices has become a salient issue in the US health care debate, as rising prices have brought increased pressure for policy action. Although Medicare has received disproportionate attention, these policies could also apply to commercial insurers, particularly to address payment differentials between hospital outpatient departments (HOPDs) and ambulatory surgical centers (ASCs). Using 2024 Transparency in Coverage data provided by Clarify Health on commercial prices for three insurers (UnitedHealthcare, Cigna, and BlueCross BlueShield), we compared payments for thirteen common procedures across settings. Overall, in 2024, commercial prices were $1,489 (78 percent) higher in HOPDs than in ASCs, whereas Medicare prices were $633 (97 percent) higher. However, site payment differentials varied substantially across payers: Cigna had the lowest differentials between HOPDs and ASCs ($327), whereas United had the highest ($1,673). Cigna achieved this through provider selection, contracting with only 14 percent of HOPDs in applicable markets compared with an average of 76 percent for United and BlueCross BlueShield. If United and BlueCross BlueShield paid Cigna’s average HOPD rates for these procedures, together they would save approximately $1.4 billion a year. Our results suggest that payers can reduce site differentials through provider selection; they also imply that larger insurers with broader networks may continue to reimburse different sites differently in the absence of either government action or a shift in market dynamics.

PMID:41052389 | DOI:10.1377/hlthaff.2025.00297

Health Aff (Millwood). 2025 Oct;44(10):1256-1265. doi: 10.1377/hlthaff.2025.00330.

ABSTRACT

Medicare-Medicaid dual enrollees accounted for roughly a third of those programs’ spending but less than 20 percent of enrollment in 2021. Policy makers have responded to dual enrollees’ high levels of spending by encouraging their enrollment in private Medicare plans. However, assessing plans’ impact on spending is complicated by favorable selection, in which healthier people prefer private plans to Medicare fee-for-service. We tested for selection into Medicare plans among dual enrollees, using linked Medicaid-Medicare claims data from the period 2017-22. We tracked people transitioning from Medicaid to dual enrollment and compared their pre-dual enrollment spending among Medicare plan choices. We found evidence of favorable selection. After adjustment for for beneficiary characteristics, a 1 percent increase in medical spending reduced beneficiaries’ probability of enrolling in private plans by 1 percentage point (2.3 percent). The effects were driven by the highest-spending beneficiaries, who were 11 percentage points (25 percent) less likely to enroll in private plans. Selection appeared to be stronger among unintegrated plans (which cover Medicare but not Medicaid benefits), although higher spending on long-term services and supports reduced enrollment in all plan types. These findings highlight the need for researchers to control for underlying health status when evaluating health or spending outcomes in private plans.

PMID:41052388 | DOI:10.1377/hlthaff.2025.00330

Health Aff (Millwood). 2025 Oct;44(10):1266-1272. doi: 10.1377/hlthaff.2025.00211.

ABSTRACT

Although its availability has grown during the past decade, pre-exposure prophylaxis (PrEP) remains underused in the US. We evaluated the impact of Medicaid expansion on state-level PrEP prescribing outcomes, using HIV surveillance data from all fifty states and Washington, D.C., from the period 2012-23, using a staggered diffeence-in-differences approach. PrEP coverage (prescriptions per 100,000 population) increased over time but was not statistically significantly associated with Medicaid expansion. There were, however, significant increases in the PrEP-to-need ratio (4.44 PrEP prescriptions per new HIV diagnosis) that were attributable to Medicaid expansion, with the strength of effects increasing over time. Medicaid expansion was associated with significant increases in PrEP-to-need ratios across all subgroups. Although Medicaid expansion effectively increased PrEP access relative to HIV diagnoses, differential impacts by race and ethnicity may suggest widening racial and ethnic disparities.

PMID:41052386 | DOI:10.1377/hlthaff.2025.00211

Health Aff (Millwood). 2025 Oct;44(10):1281-1284. doi: 10.1377/hlthaff.2025.00105.

ABSTRACT

Registered nurses (RNs) represent the largest clinical workforce in the US. We examined RN wages relative to wages for other health care occupations for the period 2012-23. Although annual inflation-adjusted wages increased across all health care occupations, RNs experienced the smallest growth (0.51 percent), and nursing assistants experienced the greatest (1.48 percent). Comparing 2012 to 2023, wage gaps between RNs narrowed compared with some professions and widened compared with others.

PMID:41052382 | DOI:10.1377/hlthaff.2025.00105

Health Aff (Millwood). 2025 Oct;44(10):1244-1249. doi: 10.1377/hlthaff.2025.00119.

ABSTRACT

Medicare Advantage (MA) enrollment has grown rapidly over recent years, and enrollees may now choose from among a large number of MA plans. However, the market remains highly concentrated, with a few very large insurers. Using MA administrative data, we analyzed trends in insurer concentration during the period 2013-23 and its relation to MA payments and plan characteristics. We documented a significant shift toward less concentration, but concentration remained high. The average number of insurers per county increased, and the Herfindahl-Hirschman Index measure of market concentration declined. Reduced concentration was associated with lower Medicare payments and individual premiums, higher plan rebates, and less enrollee cost sharing. The estimated effects, however, were quantitatively small. Our findings suggest that further reductions in MA insurer concentration may yield only modest benefits for Medicare beneficiaries and the program unless concentration falls well below current levels.

PMID:41052381 | DOI:10.1377/hlthaff.2025.00119

Health Aff (Millwood). 2025 Oct;44(10):1235-1243. doi: 10.1377/hlthaff.2025.00327.

ABSTRACT

Private equity (PE) firms and publicly traded companies own a growing share of US hospices, but little is known about differences in financial outcomes among for-profit hospices. Using 2022 Medicare cost reports, we compared revenue and expense data across four hospice ownership models: PE-owned, publicly traded company-owned, other for-profit, and not-for-profit. Adjusted analyses revealed that compared with for-profit models, not-for-profit hospices spent substantially more on direct patient care, driven by differences in nursing salaries. Relative to publicly traded company-owned and other for-profit hospices, PE-owned agencies reported the highest profits and lowest spending on direct patient care and nonsalary administrative services. PE-owned hospices also reported significantly greater expenses and revenues related to nursing facility room and board compared with all other ownership models. Our findings suggest that PE-owned hospices may follow distinct operational strategies, emphasizing nursing facility-based care and administrative efficiency while limiting direct patient care investments. Reduced spending on patient care may undermine hospice quality and shift costs to other areas of the health care system. To promote Medicare savings and better align payment with care delivery costs, policy makers could consider modifying the per diem model of hospice payment to reduce reimbursement when beneficiaries are co-located in nursing facilities.

PMID:41052380 | DOI:10.1377/hlthaff.2025.00327

J Acquir Immune Defic Syndr. 2025 Oct 6. doi: 10.1097/QAI.0000000000003767. Online ahead of print.

ABSTRACT

BACKGROUND: Advanced HIV disease is a major contributor to the slowing decline in HIV-related deaths globally. However, limited data exist on which individuals with advanced HIV are at highest risk of death.

METHODS: A retrospective cohort study was nested within a larger cohort of 13 primary care HIV treatment facilities in Khayelitsha, South Africa. All adults who had a CD4 count less than 200cells/mm3 between 1 January 2017 and 31 March 2021 were enrolled. Descriptive statistics were calculated, and the cohort was then restricted to those who had linked vital status information. We evaluated risk factors for mortality using Kaplan-Meier curves, and univariable and multivariable Cox Proportional Hazards models.

RESULTS: Between 19% and 28% of the larger cohort (n=72,102) were estimated to have advanced HIV disease at any point during the study period. Of these individuals, 20% were on treatment, 40% were disengaged from care and 40% were treatment naïve at enumeration. Overall mortality was 12%, with mortality highest in the first year (6,8%) following enumeration. There were 608, 371, and 370 deaths among those disengaged, on ART, and ART naïve respectively representing 14%, 17%, and 8% of individuals in each group. Over a quarter of all participants were found to have current tuberculosis at enrolment into the cohort.

CONCLUSION: ART-exposed individuals with advanced HIV disease contribute substantially to ongoing HIV-related mortality in South Africa. Improved adherence and retention strategies within HIV programmes could reduce this mortality.

PMID:41052372 | DOI:10.1097/QAI.0000000000003767

Personal Disord. 2025 Oct 6. doi: 10.1037/per0000746. Online ahead of print.

ABSTRACT

It has been posited that extremely high or extremely low levels of any personality trait in the five-factor model can be maladaptive. However, the Alternative Model of Personality Disorders in Section III of the Diagnostic and Statistical Manual of Mental Disorders-fifth edition (DSM-5) is composed almost exclusively of unipolar maladaptive traits. The lack of maladaptively low neuroticism and high extraversion fails to fully cover psychopathy; the lack of maladaptively high extraversion fails to cover histrionic personality disorder; the lack of maladaptively high agreeableness fails to cover dependent personality disorder; and the lack of maladaptively high conscientiousness fails to cover obsessive-compulsive personality disorder. The goal of this study was to discern whether Five-Factor Model Personality Disorder (FFMPD) scales demonstrate incremental validity over the Personality Inventory for DSM-5 (PID-5) in capturing variance in symptom measures of each of these personality disorders. A combined sample of N = 733 completed an online questionnaire battery that included the PID-5 and FFMPD scales for psychopathy, histrionic personality disorder, dependent personality disorder, and obsessive-compulsive personality disorder, along with symptom measures for each of these conditions. A series of hierarchical regression models was conducted in which each symptom measure was regressed on the PID-5 (entered in Step 1) and the corresponding FFMPD measure (entered in Step 2). Results suggest that adding the FFMPD measure to the models accounted for significantly more variance in its corresponding symptom measure than the PID-5 alone. Taken together, these results suggest that maladaptive variants of personality traits that are often considered healthy (e.g., low neuroticism, high extraversion) confer important information about personality disorder symptoms and functioning and should be included in the Alternative Model of Personality Disorders. (PsycInfo Database Record (c) 2025 APA, all rights reserved).

PMID:41051863 | DOI:10.1037/per0000746

J Nurs Educ. 2025 Oct;64(10):670-673. doi: 10.3928/01484834-20250515-03. Epub 2025 Oct 1.

ABSTRACT

BACKGROUND: Determining the extent of incivility in nursing education is critical for creating potential interventions. A survey to measure incivility, stress, well-being, and program satisfaction was developed by faculty in one Canadian nursing program.

METHOD: A cross-sectional research design was used to pilot the survey. Descriptive statistics including correlations were used to analyze the data.

RESULTS: Some of the participants reported observing other students making negative verbal remarks (42.9%) to faculty or other students, while 26.8% of participants engaged in indirect negative remarks. Receiving and engaging in incivility were strongly correlated. Fifty percent of the participants were academically stressed, correlating with incivility. Students generally were satisfied with their academic program.

CONCLUSIONS: Although incivility is reported as occurring in nursing education, not all students observed, received, or engaged in uncivil behaviors. Receiving incivility was associated with nursing students engaging in uncivil behaviors, highlighting a need for strategies to prevent or mitigate the perpetuation of incivility in undergraduate nursing education.

PMID:41051858 | DOI:10.3928/01484834-20250515-03