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ity at baseline. Psychologic symptoms were significantly associated with moderate-severe baseline disability.Although generic drugs are typically inexpensive, rising prices among some generic drugs in recent years have raised concern. Using Medicaid data, we found that one in five generic drugs sold in the US experienced a price spike (defined as a doubling in price over the course of one year) initiated by at least one manufacturer during the period 2014-17. There was a trend toward fewer price spikes each year, from 7.8 percent of drugs in 2014 to 5.8 percent in 2017. Among drugs experiencing price spikes, 51 percent were injected products, 64 percent had three or fewer manufacturers, and 18 percent were in shortage at the time of the spike. Generic drug price spikes cost Medicaid $1.5 billion during 2014-16, representing 4.2 percent of all Medicaid generic drug spending in that period. The trend toward fewer price spikes over time may be due to increased public scrutiny and regulatory actions. However, price spikes can be very costly, and additional policies are needed to both ensure adequate competition and control prices among generic drugs.Private equity firms have increasingly acquired physician practices, and particularly dermatology practices. Analyzing commercial claims from the Health Care Cost Institute (2012-17), we used a difference-in-differences design within an event study framework to estimate the prevalence of private equity acquisitions and their impact on dermatologist prices, spending, utilization, and volume of patients. By 2017 one in eleven dermatologists practiced in a private equity-owned practice, and private equity-owned practices employed four advanced practitioners for every ten dermatologists compared with three for non-private equity practices. see more Private equity firms targeted their acquisitions at larger practices that saw more commercially insured patients compared with practices that were never acquired by private equity firms. The volume of patients per private equity dermatologist ranged from 4.7 percent to 17.0 percent higher than the volume per non-private equity dermatologist up to nine quarters after acquisition. At 1.5 years after acquisition, prices paid to private equity dermatologists for routine medical visits were 3-5 percent higher than those paid to non-private equity dermatologists. There was no significant consistent impact on dermatology spending or use of biopsies, lesion destruction, or Mohs surgery. Policy makers and dermatology practice leaders may want to track the rapidly evolving phenomenon of private equity acquisitions.In recent years direct ownership of physician practices by hospitals and health systems (that is, vertical integration) has become a prominent feature of the US health care system. One unexplored impact of vertical integration is the impact on referral patterns for common diagnostic tests and procedures and the associated spending. Using a 100 percent sample of 2013-16 Medicare fee-for-service claims data, we examined whether hospital and health system ownership of physician practices was associated with changes in site of care and Medicare reimbursement rates for ten common diagnostic imaging and laboratory services. After vertical integration, the monthly number of diagnostic imaging tests per 1,000 attributed beneficiaries performed in a hospital setting increased by 26.3 per 1,000, and the number performed in a nonhospital setting decreased by 24.8 per 1,000. Hospital-based laboratory tests increased by 44.5 per 1,000 attributed beneficiaries, and non-hospital-based laboratory tests decreased by 36.0 per 1,000. Average Medicare reimbursement rose by $6.38 for imaging tests and $0.57 for laboratory tests, which translates to $40.2 million and $32.9 million increases in Medicare spending, respectively, for the entire study period. This study highlights how the growing trend of vertical integration, combined with differences in Medicare payment between hospitals and nonhospital providers, leads to higher Medicare spending.Hospice provides palliative care at the end of life, but the model fails when patients die more slowly than expected.In Kansas City, a pioneering children's hospital system has woven family feedback into its policy-making processes.The transition among many US physicians from independent practice to hospital employment has raised concerns about whether employed physicians will be more inclined to refer patients for hospital-based services that are unnecessary or inappropriate. Using claims data for 2009-16, we conducted a difference-in-differences analysis to investigate whether this form of hospital-physician integration is associated with inappropriate referrals for magnetic resonance imaging (MRI), a widely used mode of diagnostic imaging, for three common medical conditions lower back pain, knee pain, and shoulder pain. Study findings indicate that the odds of a patient receiving an inappropriate MRI referral increased by more than 20 percent after a physician transitioned to hospital employment. Most patients who received an MRI referral by an employed physician obtained the procedure at the hospital where the referring physician was employed. These results point to hospital-physician integration as a potential driver of low-value care.During the 2019 open enrollment period in California's Affordable Care Act (ACA) Marketplace, we used a randomized intervention to examine the effects of email and postal messages on choice errors, where low-income households enroll in gold or platinum plans although they are eligible for cost-sharing reduction (CSR) silver plans with lower premiums and higher actuarial values. Relative to the control group, assignment to the email-only treatment increased plan switching to CSR silver plans by 2 percentage points (an 11 percent increase), and assignment to the mail-plus-email treatment increased plan switching to CSR silver plans by 3.9 percentage points (a 22 percent increase). The mail-plus-email treatment significantly increased plan switching across all subpopulations in which choice errors were made. Consumers who switched out of a plan chosen in error saved an average of $84 per month in premiums and $56 per month in reduced out-of-pocket expenses. Our results indicate that low-cost nudges can help low-income enrollees obtain more generous coverage at a lower price and that the combination of email and postal messages is more effective at increasing plan switching than email alone to rectify choice errors.Prior research and the popular press have anecdotally reported inadequate nursing home staffing levels during the COVID-19 pandemic. Maintaining adequate staffing levels is critical to ensuring high-quality nursing home care and an effective response to the pandemic. link2 We therefore sought to examine nursing home staffing levels during the first nine months of 2020 (compared with the same period in 2019), using auditable daily payroll-based staffing data from the Centers for Medicare and Medicaid Services. We found that the total number of hours of direct care nursing declined in nursing homes during the COVID-19 pandemic, as did the average nursing home census. When we accounted for changes in census, the number of nurse staff hours per resident day remained steady or, if anything, increased slightly during the pandemic. The observed increases in staff hours per resident day were small but concentrated in nursing homes operating in counties with high COVID-19 prevalence, in nursing homes with low Medicaid census (which typically have more financial resources), and in not-for-profit nursing homes (which typically invest more in staffing). These findings raise concerns that although the number of staff hours in nursing homes did not decline, the perception of shortages has been driven by increased stresses and demands on staff time due to the pandemic, which are harder to quantify.After more than a decade of investment in electronic health information exchange (HIE), the Office of the National Coordinator for Health Information Technology is advancing a national framework-the Trusted Exchange Framework and Common Agreement-to connect islands of electronic data sharing. This national framework creates new potential opportunities and challenges for state and local health information organizations (HIOs). We undertook our sixth national HIO survey to assess the current state of HIOs and to newly examine anticipated responses to the Trusted Exchange Framework and Common Agreement. We identified eighty-nine operational HIOs, down from 106 in 2014. Although more than half of HIOs struggled with financial viability and competition from health information technology vendor-based HIE networks, many are large in scale, offer a breadth of services to diverse participants, and engage in network-to-network connectivity. Looking ahead, 56 percent of HIOs planned to participate in the Trusted Exchange Framework and Common Agreement, and 41 percent were unsure. As the Trusted Exchange Framework and Common Agreement advances basic network-to-network connectivity, HIOs that have experience with such connectivity while also offering value-added services will be well positioned for sustainability and growth.Hearing loss is associated with higher health care spending and use, but little is known about the unmet health care needs of people with hearing loss or difficulty. Analysis of 2016 Medicare Current Beneficiary Survey data for beneficiaries ages sixty-five and older reveals that those who reported a lot of trouble hearing in the past year were 49 percent more likely than those who reported no trouble hearing to indicate not having a usual source of care. Compared with those who reported no trouble hearing, those who reported some trouble hearing were more likely to indicate not having obtained medical care in the past year when they thought it was needed, as well as not filling a prescription, with the risk for both behaviors being greater among those reporting a lot of trouble hearing versus a little. link3 Interventions that improve access to hearing services and aid communication may help older Medicare beneficiaries meet their health care needs.Compared with housed people, those experiencing homelessness have longer and more expensive inpatient stays as well as more frequent emergency department visits. Efforts to provide stable housing situations for people experiencing homelessness could reduce health care costs. Through the Supportive Services for Veteran Families program, the Department of Veterans Affairs partners with community organizations to provide temporary financial assistance to veterans who are currently homeless or at imminent risk of becoming homeless. We examined the impact of temporary financial assistance on health care costs for veterans in the Supportive Services for Veteran Families program and found that, on average, people receiving the assistance incurred $352 lower health care costs per quarter than those who did not receive the assistance. These results can inform national policy debates regarding the proper solution to housing instability.The accessibility of pharmacies may be an overlooked contributor to persistent racial and ethnic disparities in the use of prescription medications and essential health care services within urban areas in the US. We examined the availability and geographic accessibility of pharmacies across neighborhoods based on their racial/ethnic composition in the thirty most populous US cities. In all cities examined, we found persistently fewer pharmacies located in Black and Hispanic/Latino neighborhoods than White or diverse neighborhoods throughout 2007-15. In 2015 there were disproportionately more pharmacy deserts in Black or Hispanic/Latino neighborhoods than in White or diverse neighborhoods, including those that are not federally designated Medically Underserved Areas. These disparities were most pronounced in Chicago, Illinois; Los Angeles, California; Baltimore, Maryland; Philadelphia, Pennsylvania; Milwaukee, Wisconsin; Dallas, Texas; Boston, Massachusetts; and Albuquerque, New Mexico. We also found that Black and Hispanic/Latino neighborhoods were more likely to experience pharmacy closures compared with other neighborhoods.