Tag: nevin manimala

Anesthesiology. 2026 Apr 3. doi: 10.1097/ALN.0000000000006080. Online ahead of print.

ABSTRACT

BACKGROUND: A substantial proportion of patients report no pain after surgery, resulting in an excess of zero values that pose challenges for analysis using traditional statistical models. The present study was designed to test the hypothesis that a two-part model, commonly used in healthcare expenditures research, would demonstrate superior performance in predicting postsurgical pain when compared to traditional models, and would secondarily better identify predictors of this clinically important outcome.

METHODS: This study analyzed a prospectively collected single-center dataset (n=3925) of chronic postsurgical pain to compare a novel two-part modeling framework with logistic and linear regression. The two-part model first estimated the probability of experiencing postsurgical pain at 3 months (binary outcome), followed by the severity of pain among those affected (on a 1-10 numeric rating scale). To obtain an unbiased assessment of model performance, the data were randomly split into training (n=3000) and testing (n=925) datasets. Models were trained on the training dataset and evaluated on the testing set. This process was repeated 400 times to compute average performance estimates. As a secondary aim, the study assessed the associations of 15 baseline factors, including validated measures of patient-reported pain, functional and psychological measures, comorbidities, and surgical details, across the different modeling approaches.

RESULTS: The two-part model demonstrated superior predictive performance compared to linear regression alone, with a higher mean R² value (0.075 vs. 0.050, p<0.0001), lower root mean square error (RMSE: 1.466 vs. 1.485, p<0.0001), and lower mean absolute error (MAE: 1.020 vs. 1.030, p<0.0001). Statistical comparison with logistic regression alone was not possible due to the shared binary component. The two-part model identified 7 baseline preoperative covariates as independently associated with postsurgical pain that were missed by either logistic or linear models, or both: self-reported race, education level, ASA classification, overall body pain, widespread pain, symptom severity, and anxiety level. Significant baseline factors identified in all three models were patient sex, surgical type, and surgical site pain.

CONCLUSION: A two-part model may offer a superior statistical approach to linear and logistic regression, better identifing patient- and clinical care-related risk factors of chronic post-surgical pain, primarily by distinguishing factors that drive the occurrence of chronic pain from those that are associated with pain severity.

PMID:41941700 | DOI:10.1097/ALN.0000000000006080

JCO Oncol Pract. 2026 Apr 6:OP2501211. doi: 10.1200/OP-25-01211. Online ahead of print.

ABSTRACT

PURPOSE: Despite strong evidence and guidelines supporting prophylactic anticoagulation for ambulatory patients with cancer starting systemic cancer-directed therapy who are at high risk of venous thromboembolism (VTE), uptake in practice is limited. We evaluated the real-world impact of prophylactic anticoagulation in such patients receiving guideline-based care.

METHODS: We conducted an observational cohort study of patients assessed as part of a multidisciplinary VTE prevention program (the Vermont model) from 2016 to 2021. For this study, we included outpatients at high risk of VTE based on a Khorana risk score or Protecht risk score of ≥3. Based on the individualized decision making, patients either received or did not receive prophylactic anticoagulation. The primary outcome was VTE at 6 months after risk assessment. The secondary outcome was all-cause mortality at 6 months.

RESULTS: Of 573 high-risk patients assessed during the study period, 340 (59%) received thromboprophylaxis and 233 (41%) did not. Eleven (3.2%) on thromboprophylaxis developed a VTE within 6 months, compared with 18 (7.7%) not on thromboprophylaxis. After adjusting for age, sex, BMI, cancer stage, chemotherapy, immunotherapy, distance from center, and history of VTE, thromboprophylaxis reduced VTE (adjusted odds ratio [OR], 0.36 [95% CI, 0.16 to 0.80]) compared with no thromboprophylaxis. Of deaths within 6 months, 57 (16.8%) occurred in the thromboprophylaxis group versus 73 (31.3%) in the no thromboprophylaxis group (adjusted OR, 0.46 [95% CI, 0.30 to 0.71]).

CONCLUSION: Ambulatory patients with cancer at high risk of VTE who received prophylactic anticoagulation had improved clinical outcomes with fewer VTE events and less mortality. Our real-world data support available clinical trial data and underscore the importance of the provision of guideline-directed care in the cancer outpatient setting.

PMID:41941694 | DOI:10.1200/OP-25-01211

Health Aff (Millwood). 2026 Apr;45(4):423-431. doi: 10.1377/hlthaff.2025.00946.

ABSTRACT

The Medicare Advantage Star Ratings program has operated for decades and directs billions of dollars in quality bonus payments, yet little is known about which measures have driven observed performance improvement over time. During the period 2015-25, most of the improvement in star ratings was concentrated in a small subset of clinically focused and medication-related measures, with nine measures accounting for more than one-third of observed gains. Medication reconciliation and medication therapy management showed the greatest improvement, while many access, preventive care, and patient experience measures showed little or no improvement. Patterns were consistent across both Part C and Part D, suggesting that gains were driven largely by medication management and other provider-led activities, rather than plan-specific responses to quality bonus incentives. Lower-performing contracts improved the most, whereas high-performing plans exhibited smaller measurable gains as a result of there being limited room for further improvement and longer measurement histories for some measures. Aligning incentives with measures that are both clinically meaningful and responsive to health plans’ actions may promote more balanced quality improvement.

PMID:41941687 | DOI:10.1377/hlthaff.2025.00946

Health Aff (Millwood). 2026 Apr;45(4):432-440. doi: 10.1377/hlthaff.2025.00916.

ABSTRACT

In 2020, Massachusetts Medicaid launched the Flexible Services Program (FSP) to fund housing and nutrition assistance services for beneficiaries in accountable care organizations. To evaluate the program’s impact on health outcomes for beneficiaries with behavioral health conditions, we compared changes in total health care costs, hospitalizations, emergency department (ED) visits, primary care visits, and hospital readmissions among 6,575 FSP participants enrolled during the period 2020-23 with those of a comparison group of people who were eligible for but did not receive FSP services. We also conducted the analysis with a secondary comparison group of 6,419 similar beneficiaries enrolled in Medicaid managed care organizations that did not offer FSP services. Relative to the primary comparison group, per person health care costs for FSP participants were $2,117 lower six months after beginning the program and $3,260 lower at twelve months. ED visits were 5 percent lower and readmissions were 36 percent lower at twelve months among FSP participants compared with the primary comparison group. Analyses using the secondary comparison group found similar reductions in costs at six months after FSP initiation, larger cost reductions at twelve months, and similar twelve-month declines in readmissions. These findings support the continuation of housing assistance programs for Medicaid beneficiaries with behavioral health conditions.

PMID:41941686 | DOI:10.1377/hlthaff.2025.00916

Health Aff (Millwood). 2026 Apr;45(4):413-422. doi: 10.1377/hlthaff.2025.00949.

ABSTRACT

In recent years, community health centers (CHCs) have struggled to meet the needs of underserved communities because of limited resources and growing demand. Medicaid and Medicare use prospective payment systems (PPSs) to reimburse CHCs at enhanced rates to safeguard their financial stability by providing consistent and predictable payments. However, whether and how these rates vary across centers is unknown. In this study, we conducted the first known analysis of Medicaid and Medicare PPS rates across CHCs by compiling a novel data set from forty-two states and Washington, D.C. We found that Medicaid PPS rates were 23 percent higher, on average, than Medicare PPS rates in 2023. Concerningly, centers that served more patients who identified as non-Hispanic Black, were uninsured, or had more chronic conditions received lower PPS rates. Overall, we observed that payment rates were generally insufficient to offset the average per visit cost of care delivered in CHCs. Standardized policies concerning how public insurance payers reimburse CHCs are needed to promote equity and sustainability in the health care safety net.

PMID:41941685 | DOI:10.1377/hlthaff.2025.00949

Health Aff (Millwood). 2026 Apr;45(4):404-412. doi: 10.1377/hlthaff.2025.01143.

ABSTRACT

The Accountable Care Organization Realizing Equity, Access, and Community Health (ACO REACH) program is a Medicare Alternative Payment Model that launched in January 2023, based on the Global and Professional Direct Contracting Model that preceded it. The transition from that program to ACO REACH was unique in the Medicare portfolio in its focus on health equity and emphasis on capitated payments. We found that in the first year of ACO REACH, 132 participating ACOs cared for more than two million Medicare beneficiaries. Nearly nine in ten ACOs met quality cutoffs for Continuous Improvement/Sustained Exceptional Performance bonuses. The average Medicare spending benchmark was approximately $16,000 per beneficiary, and nearly three-quarters of participants had spending that was lower than their benchmark. ACOs with more experience and those with a higher proportion of medically complex beneficiaries (and thus higher benchmarks) had greater savings than newer ACOs and those with lower benchmarks.

PMID:41941679 | DOI:10.1377/hlthaff.2025.01143

Health Aff (Millwood). 2026 Apr;45(4):395-403. doi: 10.1377/hlthaff.2025.01168.

ABSTRACT

In 2024, more than 90 percent of Medicare beneficiaries in Puerto Rico were enrolled in Medicare Advantage (MA) plans. MA plans receive capitated payments as well as quality-based bonuses, with MA plans operating in so-called double-bonus counties earning twice the usual bonus payments. Puerto Rico was excluded from the double-bonus payment program until 2018, when the double-bonus policy was extended to the territory. Applying a difference-in-differences approach to Centers for Medicare and Medicaid (CMS) data from the period 2012-22, we found that implementation of MA double bonuses in Puerto Rico was not associated with improvements in plan quality or changes in premiums or cost sharing, although it was associated with an increase in the number of plans offered. The findings imply that the additional payments from double bonuses primarily benefited MA plans rather than enrollees. We estimated that the policy resulted in at least $865 million in excess Medicare spending during its first five years. Together with prior evidence questioning the effectiveness of the double-bonus program, these results underscore the need for CMS to reconsider or eliminate MA double bonuses.

PMID:41941674 | DOI:10.1377/hlthaff.2025.01168

Health Aff (Millwood). 2026 Apr;45(4):378-386. doi: 10.1377/hlthaff.2025.01324.

ABSTRACT

Maryland hospitals have operated under all-payer global budget models since 2014. Within Medicare, evaluations have estimated the resulting cost savings to be $1.6 billion for the period 2014-22. To understand the aggregate inpatient and outpatient utilization changes underlying these savings and how utilization changed across all ages, we analyzed trends in Maryland relative to other states during the period 2013-23. We used national commercial claims data alongside Medicare fee-for-service claims. After we adjusted for population aging and other demographic changes, hospital utilization in Maryland decreased 11 percentage points more than in other states, primarily driven by outpatient utilization trends, which were 19 percentage points lower in Maryland than elsewhere. These results are nationally relevant, given broad interest in addressing rising hospital outpatient utilization. However, there are risks in such utilization reductions, and global budget designs must consider payment levels that are fair for both payers and providers while embedding mechanisms that maintain quality and discourage stinting on patient care.

PMID:41941672 | DOI:10.1377/hlthaff.2025.01324

Health Aff (Millwood). 2026 Apr;45(4):387-394. doi: 10.1377/hlthaff.2025.01313.

ABSTRACT

It is not currently understood whether the COVID-19 pandemic led to a lengthy period of elevated mortality rates or whether rates have returned to prepandemic trends. To examine this, I calculated age-adjusted excess mortality rates and percent excess mortality overall, by cause, and for population subgroups. COVID-19 death rates in the US fell 93 percent from 2021 to 2024, whereas excess non-COVID-19 death rates declined just 48 percent, with sustained excess mortality likely in the future, particularly for many natural causes. Suicide death rates did not rise, drug and homicide death rates jumped initially but declined relatively quickly, and transport death rates grew more moderately but showed greater persistence. Demographic-group differences were pronounced, with substantial lasting effects for females, American Indian/Alaska Native people, and seniors. This reflects heterogeneity in the prepandemic composition of deaths and in cause-specific percent excess mortality rates across groups. These results indicate important clinical and policy challenges, especially for natural causes of death and for groups facing relatively high cause-specific excess mortality rates.

PMID:41941671 | DOI:10.1377/hlthaff.2025.01313

Health Aff (Millwood). 2026 Apr;45(4):441-447. doi: 10.1377/hlthaff.2025.00644.

ABSTRACT

The Inflation Reduction Act (IRA) of 2022 changed the financing and risk-bearing obligations of Medicare Part D prescription drug plans in 2025. We used the Medicare 2021-25 public use files to construct a counterfactual trend using 2021-24 data to predict 2025 outcomes if the IRA had not implemented substantial benefit changes. We compared actual deductibles, premiums, and utilization management outcomes in 2025 against outcomes predicted by prior trends for both Medicare Advantage prescription drug (MA-PD) plans and Medicare Part D standalone prescription drug plans (PDPs). We found substantial differences between the predicted inflation-adjusted and population-weighted trend and actual deductibles for MA-PD plans (actual mean, $305.42; predicted mean, $187.54) and for PDPs (actual mean, $490.56 per month; predicted mean, $401.42 per month), as well as a decrease in premiums for MA-PD plans (actual mean, $12.76 per month; predicted mean, $15.02 per month) and for PDPs (actual mean, $39.55 per month; predicted mean, $64.07 per month). No changes were observed for prior authorization or step therapy. Formularies became smaller for protected classes and low-tier drugs in 2025 for PDPs relative to prior trend. No changes in the size of the preferred retail pharmacy networks were observed relative to prior trend.

PMID:41941670 | DOI:10.1377/hlthaff.2025.00644