About

Rachel M. Werner, MD, PhD, is the Robert D. Eilers Professor in Health Care Management and Economics at the Perelman School of Medicine, University of Pennsylvania. She is an attending physician at the Philadelphia Veterans Affairs Medical Center and a core faculty member of the Center for Health Equity Research and Promotion at the Philadelphia VAMC. Additionally, she is a senior fellow at the Leonard Davis Institute of Health Economics and a fellow at the Institute on Aging at the Perelman School of Medicine. Her research focuses on understanding how health care policies and delivery systems impact quality of care. She has examined the role of quality improvement incentives on provider behavior, the organization of health care, racial disparities, and overall health care quality. Her work has empirically investigated unintended consequences of quality improvement incentives and was among the first to recognize that public reporting of quality information may worsen racial disparities. Dr. Werner is currently the principal investigator of multiple R01 grants, including studies on pay-for-performance in hospitals and Medicaid pay-for-performance for nursing homes. She also directs a national center evaluating the effectiveness of the medical home model within the Veterans Health Administration. Her contributions have been recognized with numerous awards, including the Dissertation Award and the Alice Hersh New Investigator Award from AcademyHealth, as well as the Presidential Early Career Award for Scientists and Engineers.

Research topics

• Medicine
• Internal medicine
• Political Science
• Emergency medicine
• Sociology
• Computer Science
• Business
• Virology
• Family medicine
• Demography
• Economic growth
• Actuarial science
• Medical emergency
• Medical education
• Economics
• Public economics
• Nursing
• Pediatrics
• Intensive care medicine
• Finance
• Environmental health

Selected publications

• State Nursing Home Minimum Staffing Mandates: Increased Staff Levels, Minimal Impact On Finances And Closures, 2010–23

  Health Affairs · 2026-03-01

  articleOpen access1st authorCorresponding

  Higher levels of direct care staffing in nursing homes improve resident outcomes, yet concerns persist that minimum staffing mandates could strain facility finances or lead to closures. Using longitudinal data from the period 2010-23 on 6,849 nursing homes operating across twenty-two states, we estimated the effects of state minimum staffing mandates on staffing levels, financial health, and closures. Staffing mandates increased total direct care staff by 0.18 hours per resident day, or roughly 5 percent, on average, driven by increases in licensed practical nurses (0.06 hours per resident day) and certified nursing assistants (0.13 hours per resident day). Facilities' annual labor expenses rose by about $273,000, but these costs were offset by higher net patient revenues (approximately $546,000), leaving net margins unchanged. Mandates did not increase the likelihood of facility closure. Overall, our findings indicate that minimum staffing mandates can meaningfully raise staffing levels without undermining the financial viability of nursing homes.

  PublisherOA PDFDOI

• Is Medicare Home Health Care Utilization Substituting for Long‐Term Care? Evidence From Dual Eligible Beneficiaries

  Health Services Research · 2026-04-01

  articleOpen access

  OBJECTIVE: To examine the plausibly causal effect of Medicaid home- and community-based services (HCBS) use on Medicare community-initiated home health care (CIHHC) utilization among dual-eligible older adults and to provide evidence on whether access to home-based long-term care (LTC) reduces use of Medicare home health care, with potential implications for whether Medicare home health care is used as a substitute for LTC services when they are not or less accessible. STUDY SETTING AND DESIGN: To address the endogeneity of Medicaid HCBS use, we employ an instrumental variable, the proportion of Medicaid HCBS enrollment in other counties within the same state in the previous quarter, in conjunction with a state-border design in estimating the effect of Medicaid HCBS use on Medicare CIHHC and its heterogeneity. DATA SOURCES AND ANALYTIC SAMPLE: We use national Medicare and Medicaid claims data along with home health and nursing home assessment data from 2016 to 2019. Our sample consists of 36,955,226 beneficiary-quarter-level observations of older adults (65+) dually enrolled in Medicaid and Medicare and residing in contiguous state-border counties. PRINCIPAL FINDINGS: Medicaid HCBS use reduces Medicare CIHHC utilization by approximately 1.02 percentage points (95% CI: -1.73 to -0.32), representing about 44% of the sample mean. This effect is concentrated among beneficiaries enrolled in Medicare-Medicaid integrated care plans and those living in urban counties. Moreover, the reduction is most pronounced among older adults who live alone and have around-the-clock assistance needs. CONCLUSIONS: Our findings suggest a substitution between Medicaid HCBS and Medicare CIHHC among dual-eligible older adults at the margin of using Medicaid HCBS, a relationship that should be taken into account when evaluating either program. These findings also align with the hypothesis that Medicare CIHHC is being used as a substitute for LTC, and the availability of home-based LTC may help to alleviate this potentially inefficient use.

  PublisherDOI

• Rural Health Transformation Program Allocations and Rural Health Needs in the US

  JAMA · 2026-03-05

  articleOpen accessSenior author

  This study examines associations between recently released state-level Rural Health Transformation Program funding and measures of rural health, access, and projected reductions in Medicaid spending.

  PublisherOA PDFDOI

• On the same (evaluation) page: a novel approach to enhance mixed-methods implementation evaluation

  BMJ Open Quality · 2025-07-01

  articleOpen access

  Quality improvement and implementation science evaluations are often complex mixed methods approaches conducted by interdisciplinary teams. These efforts are challenging in normal circumstances; the COVID-19 pandemic and subsequent shift to remote work have posed additional challenges to this type of work. Novel approaches, tools, and processes may be needed to improve the rigor and cohesion of mixed methods evaluations, especially with a team working remotely.Quality improvement and implementation science evaluations are often complex mixed methods approaches conducted by interdisciplinary teams. These efforts are challenging in normal circumstances; the COVID-19 pandemic and subsequent shift to remote work have posed additional challenges to this type of work. Novel approaches, tools, and processes may be needed to improve the rigor and cohesion of mixed methods evaluations, especially with a team working remotely.Our aim was to create a rigorous evaluation plan for a large hybrid type III implementation-evaluation trial implementing new evidence-based processes at nine medical centers. Given the trial's complexity and a geographically-distributed remotely-working interdisciplinary team, we found that existing tools did not meet our needs. We thus created a novel process for developing a rigorous evaluation plan that others could replicate.This process has seven steps: 1) select a template and identify point person; 2) complete initial development; 3) obtain targeted asynchronous feedback; 4) identify and analyze gaps; 5) conduct targeted virtual synchronous discussion; 6) finalize working document; and 7) apply the plan and solicit ongoing feedback.Interdisciplinary quality improvement and implementation science project teams need tools and processes to ensure clear communication, well-ordered workflow, and rigorous operationalization of evaluation aims. The seven-step evaluation plan tool not only helped to enhance the rigor and execution of a large program evaluation, but the process also served an important convening function to enhance coordination between remote team members. Our work builds on existing processes for evaluation plan development while incorporating team science approaches.

  PublisherOA PDFDOI

• Immigration Enforcement, the Supply of Home Care Workers, and Access to Long-Term Care: Evidence from Secure Communities <br>

  SSRN Electronic Journal · 2025-01-01

  preprintOpen accessSenior author
  PublisherDOI

• Mixed Evidence That Rural Hospitals’ Finances Improved With Participation In The Pennsylvania Rural Health Model

  Health Affairs · 2025-07-01 · 1 citations

  articleSenior author

  The voluntary Pennsylvania Rural Health Model (PARHM) provided participating rural hospitals with global budgets rather than traditional fee-for-service payments to improve financial stability. Whether participation in PARHM was associated with financial improvements is unknown. In this synthetic difference-in-differences study from the period 2014-23, we estimated changes in rural hospital finances associated with PARHM participation among seventeen PARHM participants and forty nonparticipating Pennsylvania comparison hospitals. In unadjusted models, participation was associated with a 4.5-percentage-point differential increase in operating margins and a 4.7-percentage-point differential increase in total margins; however, these changes were nonsignificant in adjusted models (3.0 and 3.2 percentage points, respectively). Results were similar when we compared PARHM participants with 160 border-state comparison hospitals and when we used alternative difference-in-differences estimators. These findings offer mixed evidence that global budgets may help stabilize rural hospital finances in the short term.

  PublisherDOI

• Real-world quantification of implementation dose across twenty-five implementation instances

  Implementation Science Communications · 2025-11-29

  articleOpen access

  BACKGROUND: There are many approaches in implementation science research and practice to prospectively and pragmatically measure the amount of effort required to implement a particular evidence-based practice (EBP). We sought to 1) demonstrate how to prospectively and pragmatically document implementation activities in a real-world implementation trial; 2) quantify implementation dose (frequency and time spent) across the implementation of four EBPs; and 3) explore potential drivers of variation in implementation dose across EBP, sites, implementation progress, and wave. METHODS: We built on the existing literature to develop a prospective and pragmatic way to track implementation activities during a type III hybrid effectiveness-implementation stepped wedge trial. We then quantified both total implementation dose (defined as total time spent by the implementer team) and how much of this dose was synchronous (defined as time spent working directly with local implementers at the sites receiving the intervention). We used multiple linear regression to understand what factors may influence differences in total implementation dose delivered (such as which evidence-based practice was being implemented, in which wave of the stepped wedge, at which medical centers), as well as how dose was related to implementation progress, categorized by 1) decision to participate, 2) training, 3) implementation with support, and 4) independent implementation. RESULTS: From 2022 to 2023, we prospectively captured implementation dose across 25 implementation instances related to four EBPs that were implemented at seven VA medical centers. We implemented Surgical Pause seven times, TAP six times, CAPABLE six times, and EMPOWER six times. We captured and categorized 1,271 h of implementation activities. Asynchronous administrative activities were most common across implementation phases. Other common synchronous activities include engaging collaborators, problem solving, providing updates, and ongoing action/implementation planning. The EBP was the largest driver of variation in implementation dose overall. Site, implementation progress, and wave did not independently explain variations in implementation dose. CONCLUSIONS: The EBP being implemented was a much stronger predictor of the implementation dose required than were other factors, such as experience implementing the EBP or characteristics of the medical center where the intervention was being implemented.

  PublisherDOI

• Medicare’s Skilled Nursing Facility Value-Based Purchasing Program Fails to Lower Hospital Readmissions

  ScholarlyCommons (University of Pennsylvania) · 2025-01-01

  otherOpen accessSenior author

  Since it launched in 2015, Medicare’s Skilled Nursing Facility Value-Based Purchasing Program has failed to reduce hospital readmissions as intended. Fortunately, it does not increase deaths, nor does it appear to delay needed rehospitalizations. The program’s new performance measures and incentives could help it achieve its goals.

  Publisher

• Home Health Care Use Among Medicare Beneficiaries From 2010 to 2020

  Medical Care Research and Review · 2025-02-19 · 7 citations

  articleOpen accessSenior author

  Medicare home health coverage is an important resource for Medicare beneficiaries requiring health care at home. However, there have been changes in the United States health care system that might impact home health utilization such as pressures to constrain Medicare spending, growth in Medicare Advantage (MA) plan enrollment, decline in institutional long-term care and growth of Medicaid home- and community-based services. Given these changes, we examined home health care use trends among beneficiaries enrolled in traditional Medicare (TM) and MA from 2010 to 2020. We separately examined home health episodes that were initiated after a hospital or skilled nursing facility discharge and those initiated within the community and among dually and non-dually eligible beneficiaries. Home health use decreased among TM enrollees for both community-initiated and post-discharge needs but increased among MA enrollees for community-initiated home health use. Increases in community-initiated home health use were concentrated in non-dually eligible beneficiaries.

  PublisherDOI

• Payments to Physician Practices and Incentives to Serve Different Racial and Ethnic Groups

  JAMA Health Forum · 2025-11-26

  articleOpen accessSenior author

  Importance: In the US, a physician can be paid very different amounts for treating different patients, even when providing identical services. Understanding physician practices' financial incentives to serve different racial and ethnic groups may help inform payment policies to reduce health disparities. Objective: To measure disparities across patient racial and ethnic groups in per-visit payment to physician practices from health insurers and other sources, adjusted for visit content, geographic market, and year, and to quantify the role of health insurance source and other factors in these disparities. Design, Setting, and Participants: A unique, nationally representative dataset of outpatient visits containing survey-obtained patient race and ethnicity and payment amounts to physician practices from health insurers and other sources was analyzed. Data were collected from 2014 to 2021. Main Outcomes and Measures: Payment disparities were defined as gaps between patient groups defined by race and ethnicity in total payments per visit to physician practices, adjusted for visit content, geographic market, and year. Kitagawa-Oaxaca-Blinder decompositions were used to estimate the magnitude of these disparities and to quantify the roles of factors like health insurance. Results: The sample included 38 722 patients and 152 336 outpatient visits for evaluation and management services; a total of 8126 (21.0%) were Hispanic, 6150 (15.9%) were non-Hispanic Black, and 24 446 (63.1%) were non-Hispanic White. A total of 152 336 outpatient visits were included for evaluation and management services. In adjusted analyses, outpatient payments were 8.8% (95% CI, 6.7-11.0) less for visits with non-Hispanic Black patients and 9.8% (95% CI, 7.2-12.4) less for visits with Hispanic patients compared with visits with non-Hispanic White patients. Payment gaps were largest for children (13.9% [95% CI, 11.8-16.0] for non-Hispanic Black children; 15.1% [95% CI, 12.8-17.4] for Hispanic children), smaller when adjusted for insurance source (4.9% [95% CI, 2.7-7.1] for non-Hispanic Black patients; 5.6% [95% CI, 3.0-8.3] for Hispanic patients), and absent among patients with fee-for-service Medicare (1.2% [95% CI, -1.5 to 3.9] for non-Hispanic Black patients; -0.6% [95% CI, -4.4 to 3.2] for Hispanic patients). Conclusions and Relevance: In this study, US physician practices were paid more for outpatient visits with non-Hispanic White patients than for outpatient visits with Hispanic or non-Hispanic Black patients. Payment disparities were larger in pediatrics and partly explained by insurance. Differential financial incentives to serve non-Hispanic White patients may worsen disparities in health care access, utilization, and quality.

  PublisherOA PDFDOI

Recent grants

• NIH Grant R01HS016478

  NIH · $829k · 2010

• Postdoctoral Training in Health Services Research

  NIH · $3.8M · 2018–2028

• Evaluating Pay for Performance and its Design: Evidence from Nursing Homes

  NIH · $1.3M · 2010–2017

• The effectiveness of post-acute care

  NIH · $710k · 2015–2019

• The Impact of ACOs on Disparities

  NIH · $1.0M · 2017–2021

Frequent coauthors

• R. Tamara Konetzka

  University of Chicago

  129 shared

• G. Arling

  Purdue University West Lafayette

  121 shared

• Courtney H. Van Houtven

  Duke University

  99 shared

• Kathleen T. Unroe

  Indiana University

  99 shared

• Christine E. Bishop

  Brandeis University

  99 shared

• Brystana G. Kaufman

  Center for Neuro-Oncology

  99 shared

• Katherine Miller

  Johns Hopkins University

  90 shared

• Ryan Gilmartin

  University of Michigan–Ann Arbor

  88 shared

Awards & honors

• Dissertation Award from AcademyHealth
• Alice Hersh New Investigator Award from AcademyHealth
• Presidential Early Career Award for Scientists and Engineers