Interactive network visualization of opioid crisis research: a tool for reinforcing data linkage skills for public health policy researchers

Background

Public health policy researchers face a persistent challenge in identifying and integrating relevant data, particularly in the context of the U.S. opioid crisis, where a comprehensive approach is crucial.

Purpose

To meet this new workforce demand health policy and health economics programs are increasingly introducing data analysis and data visualization skills. Such skills facilitate data integration and discovery by linking multiple resources. Common linking strategies include individual or aggregate level linking (e.g., patient identifiers) in primary clinical data and conceptual linking (e.g., healthcare workforce, state funding, burnout rates) in secondary data. Often, the combination of primary and secondary datasets is sought, requiring additional skills, for example, understanding metadata and constructing interlinkages.

Methods

To help improve those skills, we developed a 2-step process using a scoping method to discover data and network visualization to interlink metadata. Results: We show how these new skills enable the discovery of relationships among data sources pertinent to public policy research related to the opioid overdose crisis and facilitate inquiry across heterogeneous data resources. In addition, our interactive network visualization introduces (1) a conceptual approach, drawing from recent systematic review studies and linked by the publications, and (2) an aggregate approach, constructed using publicly available datasets and linked through crosswalks.

Conclusions

These novel metadata visualization techniques can be used as a teaching tool or a discovery method and can also be extended to other public policy domains.

Designing Difference-in-Difference Studies with Staggered Treatment Adoption: Key Concepts and Practical Guidelines

Difference-in-difference (DID) estimators are a valuable method for identifying causal effects in the public health researcher's toolkit. A growing methods literature points out potential problems with DID estimators when treatment is staggered in adoption and varies with time. Despite this, no practical guide exists for addressing these new critiques in public health research. We illustrate these new DID concepts with step-by-step examples, code, and a checklist. We draw insights by comparing the simple 2 × 2 DID design (single treatment group, single control group, two time periods) with more complex cases: additional treated groups, additional time periods of treatment, and treatment effects possibly varying over time. We outline newly uncovered threats to causal interpretation of DID estimates and the solutions the literature has proposed, relying on a decomposition that shows how the more complex DID are an average of simpler 2 × 2 DID subexperiments. Expected final online publication date for the Annual Review of Public Health, Volume 45 is April 2024. Please see http://www.annualreviews.org/page/journal/pubdates for revised estimates.

The Impact of State Medicaid Eligibility and Benefits Policy on Neonatal Abstinence Syndrome Hospitalizations

Rates of neonatal abstinence syndrome (NAS) resulting from opioid misuse are rising. However, policies to treat opioid misuse during pregnancy are unclear. We apply a difference-in-differences design to national pediatric discharge records to examine the effects of state Medicaid policies on NAS. Among states in which Medicaid covered two clinically-recommended medications for treating opioid misuse (buprenorphine, methadone), the Affordable Care Act's Medicaid expansion reduced Medicaid-covered NAS hospitalizations. Medicaid expansion did not affect NAS hospitalizations in other expansion states. These findings imply a nuanced relationship between Medicaid policy and NAS that should be considered in addressing opioid misuse among pregnant women.

Racial/ethnic disparities in timely receipt of buprenorphine among Medicare disability beneficiaries

BACKGROUND

Medicare disability beneficiaries (MDBs) have disproportionately high risk of opioid use disorder (OUD) and related harms given high rates of comorbidities and high-dose opioid prescribing. Despite this increased risk, little is known about timely receipt of medication for opioid use disorder (MOUD), including potential disparities by patient race/ethnicity or moderation by county-level characteristics.

METHODS

National Medicare claims for a sample of MDBs with incident OUD diagnosis between March 2016 and June 2019 were linked with county-level data. Multivariable mixed effects Cox proportional hazards models estimated time (in days) to buprenorphine receipt within 180 days of incident OUD diagnosis. Primary exposures included individual-level race/ethnicity and county-level buprenorphine prescriber availability, percent non-Hispanic white (NHW) residents, and Social Deprivation Index (SDI) score.

RESULTS

The sample (n=233,079) was predominantly White (72.3%), ≥45 years old (76.3%), and male (54.8%). Black (adjusted hazard ratio [aHR]=0.50; 95% CI, 0.47-0.54), Asian/Pacific Islander (aHR=0.54; 95% CI, 0.41-0.72), Hispanic/Latinx (aHR=0.81; 95% CI, 0.76-0.87), and Other racial/ethnic groups (aHR=0.75; 95% CI, 0.58-0.97) had a lower likelihood of timely buprenorphine than non-Hispanic white beneficiaries after adjusting for individual and county-level confounders. Timely buprenorphine receipt was positively associated with county-level buprenorphine prescriber availability (aHR=1.05; 95% CI, 1.04-1.07), percent non-Hispanic white residents (aHR=1.01; 95% CI, 1.00-1.01), and SDI (aHR=1.06; 95% CI, 1.01-1.10).

CONCLUSIONS

Racial/ethnic disparities highlight the need to improve access to care for underserved groups. Implementing equity-focused quality and performance measures and developing interventions to increase office-based buprenorphine prescribing in predominantly minority race/ethnicity counties may reduce disparities in timely access to medication for OUD.

Transparency in Coverage Data and Variation in Prices for Common Health Care Services

This cross-sectional study describes the health care prices publicly posted by Humana and the price variations by geography, service, and other factors.

Collective aeromedical evacuations of SARS-CoV-2-related ARDS patients in a military tactical plane: a retrospective descriptive study

After the appearance of the COVID-19 pandemic in France, MEROPE system was created to transform the military tactical ATLAS A400M aircraft into a flying intensive care unit. Collective aeromedical evacuations (aero-MEDEVAC) of patients suffering from SARS-CoV-2-related acute respiratory distress syndrome was performed from June to December 2020. A total of 22 patients were transported during seven missions. All aero-MEDEVAC was performed in safe conditions for patients and crew. No life-threatening conditions occurred during flight. Biohazard controls were applied according to French guidelines and prevented crew contamination. Thanks to rigorous selection criteria and continuous in-flight medical care, the safe transportation of these patients was possible. To the best of our knowledge, this is the first description of collective aero-MEDEVAC of these kinds of patients using a tactical military aircraft. We here describe the patient's characteristics and the flight's challenges.

Competitive effects of federal and state opioid restrictions: Evidence from the controlled substance laws

A significant concern in the policy landscape of the U.S. opioid crisis is whether supply-side controls can reduce opioid prescribing without harmful substitution. We consider an unstudied policy: the federal Controlled Substance Act (CSA) restrictions placed in August 2014 on tramadol, the second most popular opioid medication. This was followed seven weeks later by CSA restrictions for hydrocodone combination products, the leading opioids on the market. Using regression discontinuity design (RDD) models, based on the timing of the (up-)scheduling changes, to explore spillover effects, we find that tightening prescribing restrictions on one opioid reduces its use, but increases prescribing of close competitors, leading to no reduction in total opioid prescriptions.This suggests that supply restrictions are not effective in reducing opioid prescribing the presence of close substitutes that remain unrestricted.

Mortality and Discharge Location of Intensive Care Patients With Alzheimer Disease and Related Dementia

BACKGROUND

Intensive care unit (ICU) utilization has increased among patients with Alzheimer disease and related dementia (ADRD), although outcomes are poor.

OBJECTIVES

To compare ICU discharge location and subsequent mortality between patients with and patients without ADRD enrolled in Medicare Advantage.

METHODS

This observational study used Optum's Clinformatics Data Mart Database from years 2016 to 2019 and included adults aged >67 years with continuous Medicare Advantage coverage and a first ICU admission in 2018. Alzheimer disease and related dementia and comorbid conditions were identified from claims. Outcomes included discharge location (home vs other facilities) and mortality (within the same calendar month of discharge and within 12 months after discharge).

RESULTS

A total of 145 342 adults met inclusion criteria; 10.5% had ADRD and were likely to be older, female, and have more comorbid conditions. Only 37.6% of patients with ADRD were discharged home versus 68.6% of patients who did not have ADRD (odds ratio [OR], 0.40; 95% CI, 0.38-0.41). Both death in the same month as discharge (19.9% vs 10.3%; OR, 1.54; 95% CI, 1.47-1.62) and death in the 12 months after discharge (50.8% vs 26.2%; OR, 1.95; 95% CI, 1.88-2.02) were twice as common among patients with ADRD.

CONCLUSIONS

Patients with ADRD have lower home discharge rates and greater mortality after an ICU stay than patients without ADRD.

Does paid sick leave encourage staying at home? Evidence from the United States during a pandemic

We study the impact of a temporary U.S. paid sick leave mandate that became effective April 1st, 2020 on self-quarantining, proxied by physical mobility behaviors gleaned from cellular devices. We study this policy using generalized difference-in-differences methods, leveraging pre-policy county-level heterogeneity in the share of workers likely eligible for paid sick leave benefits. We find that the policy leads to increased self-quarantining as proxied by staying home. We also find that COVID-19 confirmed cases decline post-policy.

Trends in Methadone Dispensing for Opioid Use Disorder After Medicare Payment Policy Changes

Importance

A significant proportion of Medicare beneficiaries have a diagnosed opioid use disorder (OUD). Methadone and buprenorphine are both effective medications for the treatment of OUD (MOUDs); however, Medicare did not cover methadone until 2020.

Objective

To examine trends in methadone and buprenorphine dispensing among Medicare Advantage (MA) enrollees after 2 policy changes in 2020 related to methadone access.

Design, Setting, and Participants

This cross-sectional analysis of temporal trends in methadone and buprenorphine treatment dispensing assessed MA beneficiary claims from January 1, 2019, through March 31, 2022, captured by Optum's Clinformatics Data Mart. Of 9 870 791 MA enrollees included in the database, 39 252 had at least 1 claim for methadone, buprenorphine, or both during the study period. All available MA enrollees were included. Subanalyses by age and dual eligibility for Medicare and Medicaid status were conducted.

Exposures

Study exposures were (1) the Centers for Medicare & Medicaid Services (CMS) Medicare bundled payment reimbursement policy for OUD treatment and (2) the Substance Abuse and Mental Health Administration and CMS Medicare policies designed to facilitate access to treatment for OUD, specifically during the COVID-19 pandemic.

Main Outcomes and Measures

Study outcomes were trends in methadone and buprenorphine dispensing by beneficiary characteristics. National methadone and buprenorphine dispensing rates were calculated as claims-based dispensing rates per 1000 MA enrollees.

Results

Among the 39 252 MA enrollees with at least 1 MOUD dispensing claim (mean age, 58.6 [95% CI, 58.57-58.62] years; 45.9% female), 195 196 methadone claims and 540 564 buprenorphine pharmacy claims were identified, for a total of 735 760 dispensing claims. The methadone dispensing rate for MA enrollees was 0 in 2019 because the policy did not allow any payment until 2020. Claims rates per 1000 MA enrollees were low initially, increasing from 0.98 in the first quarter of 2020 to 4.71 in the first quarter of 2022. Increases were primarily associated with dually eligible beneficiaries and beneficiaries younger than 65 years. National buprenorphine dispensing rates were 4.64 per 1000 enrollees in quarter 1 of 2019, increasing to 7.45 per 1000 enrollees in quarter 1 of 2022.

Conclusions and Relevance

This cross-sectional study found that methadone dispensing increased among Medicare beneficiaries after the policy changes. Rates of buprenorphine dispensing did not provide evidence that beneficiaries substituted buprenorphine for methadone. The 2 new CMS policies represent an important first step in increasing access to MOUD treatment for Medicare beneficiaries.

Trends in Abortion- and Contraception-Related Internet Searches After the US Supreme Court Overturned Constitutional Abortion Rights: How Much Do State Laws Matter?

Importance

The US Supreme Court ruling in Dobbs v Jackson Women's Health Organization on June 24, 2022, revealed immediate and distinct differences between states regarding abortion legality. Whether the ruling was associated with population-level changes in seeking information on reproductive health care-related information is unknown.

Objective

To determine whether the US Supreme Court ruling on Dobbs v Jackson Women's Health Organization was associated with increased information seeking for reproductive health care access in the states with immediately effective (trigger and pre-Roe) abortion laws vs other states.

Design, Setting, and Participants

This was a retrospective cross-sectional study of nationwide real-time internet search data by state-week from January 1, 2021, through July 16, 2022. Difference-in-difference event study estimates were used to evaluate abortion- and contraception-related internet searches after the Supreme Court draft majority decision was leaked on May 2, 2022, and the final ruling was issued on June 24, 2022, in states immediately affected vs other states. Data analyses were performed from July 18 to January 14, 2022.

Exposures

The Supreme Court's draft majority decision leaked on May 2, 2022, and the final ruling on Dobbs v Jackson Women's Health Organization on June 24, 2022. Preexisting state trigger laws and pre-Roe bans that became effective immediately when Roe was overturned by the decision on Dobbs.

Main Outcomes and Measures

Number of searches per 10 million Google queries in a state-week for terms related to abortion or contraception.

Results

Searches for abortion-related terms increased from 16 302 to 75 746 per 10 million searches per state-week during the weeks before vs after the May 2, 2022, leak of the draft majority decision in states with trigger laws or abortion bans. This was a 42% (95% CI, 24%-59%) higher increase than in states with laws that protect abortion access. Searches for contraception also increased from 56 055 to 82 133 searches per state-week after the ruling in the states with abortion bans, 25% (95% CI, 13%-36%) higher than the increase in states protecting abortion access.

Conclusions and Relevance

The findings of this retrospective cross-sectional study suggest that changes in internet searching for terms related to reproductive health care can capture immediate population-level changes in information-seeking behavior regarding reproductive health care access. These data are critical for shaping health policy discussions.

Opioid Prescriptions Prior to Emergency Department Dental Visits: A Comparison of Dental Health Professional Shortage Areas (DPSAs) and Non-DPSAs Using Electronic Health Records

Although prior research has linked dental conditions and opioid prescribing in the U.S., it is not yet known whether the receipt of opioid prescriptions prior to seeking emergency care for dental conditions differs in geographical areas that are underserved by health care professionals (Dental Professional Shortage Areas, DPSAs) compared to other areas. Using Indiana's state-wide electronic health records from January 1, 2016 to October 31, 2020, we examine if patients from DPSAs presenting at the emergency department (ED) for dental conditions are more likely to have received opioid prescriptions in the 30 days prior to their visit, compared to patients from other areas. A higher rate of opioid receipt among DPSA individuals may indicate an association between lower availability of dental professionals and the use of opioids as a coping strategy. We note that our study design has several limitations (such as a lack of data on prescription use after the ED visit) and does not prove causation. We find that individuals experiencing dental condition ED visits in DPSAs are 16% more likely (than those in non-DPSAs) to have filled an opioid prescription in the 30 days prior to the ED visit, after controlling for age, gender, and race/ethnicity. This result is statistically significant at the 1% level. The baseline rate of opioid filling in the 30 days prior to the ED visit is 12% in DPSAs. These correlational results suggest that unmet dental needs might be substantially connected to opioid prescriptions, although further research is needed to establish whether this relationship is causal.

A National Retrospective Study of Antidepressants' Effects on Overdose and Self-Harm Among Adults Treated With Opioid Analgesics

OBJECTIVE

Because individuals with a history of depression who are receiving opioids are at higher risk for adverse events, the authors examined whether antidepressant treatment reduces risk for overdose and self-harm among individuals with a history of depression who receive opioids.

METHODS

Commercial insurance claims of individuals with a history of depression receiving opioids from 2007 to 2017 were used to quantify the association between antidepressant fills and adverse events among individuals after initiation of opioid treatment; the authors accounted for selection into treatment and used discrete-time, proportional hazards survival models.

RESULTS

Among 283,374 adults with a history of depression treatment, 8,203 experienced 47,486 adverse events from 2007 to 2017 in the 12 months after initiation of opioid treatment. Approximately half (N=144,052, 50.8%) filled an antidepressant prescription at least once in the 12 months after the opioid episode began. Individuals receiving antidepressants for at least 6 weeks had a reduced risk for any adverse event (adjusted odds ratio [AOR]=0.79, 95% confidence interval [CI]=0.65-0.97) as well as a reduced risk for opioid overdoses (AOR=0.78, 95% CI=0.64-0.96), overdoses from nonopioid controlled substances (AOR=0.76, 95% CI=0.62-0.94), overdoses from other substances (AOR=0.79, 95% CI=0.65-0.97), and other self-harm events (AOR=0.82, 95% CI=0.67-1.00).

CONCLUSIONS

Individuals with a history of depression who received opioid analgesics had a significantly lower risk for overdose and self-harm after they had been taking antidepressants for at least 6 weeks. Universal screening for mood disorders among individuals receiving opioids, and promptly providing evidence-based depression treatment when appropriate, may reduce adverse events.

Effects of social distancing policy on labor market outcomes

US workers receive unemployment benefits if they lose their job, but not for reduced working hours. In alignment with the benefits incentives, we find that the labor market responded to COVID-19 and related closure-policies mostly on the extensive (12 pp outright job loss) margin. Exploiting timing variation in state closure-policies, difference-in-differences (DiD) estimates show, between March 12 and April 12, 2020, employment rate fell by 1.7 pp for every 10 extra days of state stay-at-home orders (SAH), with little effect on hours worked/earnings among those employed. Forty percentage of the unemployment was due to a nationwide shock, rest due to social-distancing policies, particularly among "non-essential" workers.

Recent tapering from long-term opioid therapy and odds of opioid-related hospital use

PURPOSE

The number of patients tapered from long-term opioid therapy (LTOT) has increased in recent years in the United States. Some patients tapered from LTOT report improved quality of life, while others face increased risks of opioid-related hospital use. Research has not yet established how the risk of opioid-related hospital use changes across LTOT dose and subsequent tapering. Our objective was to examine associations between recent tapering from LTOT with odds of opioid-related hospital use.

METHODS

Case-crossover design using 2014-2018 health information exchange data from Indiana. We defined opioid-related hospital use as hospitalizations, and emergency department (ED) visits for a drug overdose, opioid abuse, and dependence. We defined tapering as a 15% or greater dose reduction following at least 3 months of continuous opioid therapy of 50 morphine milligram equivalents (MME)/day or more. We used conditional logistic regression to estimate odds ratios (OR) with 95% confidence intervals (CI).

RESULTS

Recent tapering from LTOT was associated with increased odds of opioid-related hospital use (OR: 1.50, 95%CI: 1.34-1.63), ED visit (OR: 1.52; 95%CI: 1.35-1.72), and inpatient hospitalization (OR: 1.40; 95%CI: 1.20-1.65). We found no evidence of heterogeneity of the effect of tapering on opioid-related hospital use by gender, age, and race. Recent tapering among patients on a high baseline dose (>300 MME) was associated with increased odds of opioid-related hospital use (OR: 2.95, 95% CI: 2.12-4.11, p < 0.001) compared to patients on a lower baseline doses.

CONCLUSIONS

Recent tapering from LTOT is associated with increased odds of opioid-related hospital use.

Perceived COVID-19 vaccine attributes associated with early adoption among adults in rural Indiana

2019 Novel coronavirus (COVID-19) vaccination rates in the United States have plateaued in specific populations, including rural areas. To improve COVID-19 vaccination rates and to encourage early vaccine uptake in future pandemics, this study aimed to examine vaccine attributes associated with early adoption. Data are from an anonymous online survey of adults using targeted Facebook pages of rural southern Indiana towns in January and February 2021 (n = 286). The diffusion of innovation theory states that the rate of adoption of a product in a specific population is explained by five perceived attributes: relative advantage, compatibility, observability, complexity and trialability. Binary logistic regression analyses were used to examine the association of Diffusion of Innovation theory attributes of the COVID-19 vaccine on early adoption. Results indicated that trialability [odds ratio (OR) = 3.307; 95% confidence interval (CI) = 1.964-5.571; P < 0.001], relative advantage (OR = 2.890; 95% CI = 1.789-4.667; P < 0.001) and compatibility (OR = 2.606; 95% CI = 1.476-4.601; P < 0.001) showed significant independent associations with early adoption. Furthermore, age and political ideology were significant moderators of complexity and relative advantage, respectfully. Health education strategies for early vaccine uptake should focus on building trust in vaccine safety, increasing short-term benefits of vaccination and promoting relatability to personal values.

Analysis of US County Characteristics and Clinicians With Waivers to Prescribe Buprenorphine After Changes in Federal Education Requirements

This cross-sectional study investigates the growth in the number of clinicians in the US who obtained waivers for prescribing buprenorphine after the elimination of federal educational requirements.

COVID-19 booster uptake among US adults: Assessing the impact of vaccine attributes, incentives, and context in a choice-based experiment

OBJECTIVE

Evidence shows that booster shots offer strong protection against the Omicron variant of COVID-19. However, we know little about why individuals would receive a booster compared to the initial decision to vaccinate. We investigate and assess the factors that affect individuals' reported willingness to receive the COVID-19 vaccine booster. This information can aid in tailoring public health messaging to communicate attributes that are associated with individuals' attitudes toward the COVID-19 booster.

RATIONALE

Existing research provides little insight into whether the same factors that affect Americans' likelihood of accepting initial vaccination against COVID-19 also affect booster uptake. Our experiment also examines the influence of contextual information about a novel variant on willingness to receive a booster.

METHODS

We administered a conjoint experiment (N = 2740 trials) in a survey of fully vaccinated US adults that had not yet received a COVID-19 booster (N = 548) to assess the impact of varied vaccine attributes on willingness to receive a booster.

RESULTS

The most important factors associated with higher willingness to receive a booster were efficacy, manufacturer, and the size of a financial incentive. Protection duration and protection against future variants vs. only current variants had modest influence. A contextual prime reporting that some public health experts believe the Omicron variant is more contagious, but less lethal than those previously seen, significantly increased favorability toward boosters. This provides potential motivation and guidance for vaccination campaigns to emphasize these variant-specific traits.

CONCLUSION

With several vaccines with varying degrees of efficacy available to consumers, emphasizing boosters with a high efficacy would likely improve attitudes toward boosters. Financial incentives and predispositions toward manufacturers also matter. Concerns about more contagious variants may spur uptake, even if such variants are less lethal.

Characteristics of statewide prescription drug monitoring programs and potentially inappropriate opioid prescribing to patients with non-cancer chronic pain: A machine learning application

Unnecessary/unsafe opioid prescribing has become a major public health concern in the U.S. Statewide prescription drug monitoring programs (PDMPs) with varying characteristics have been implemented to improve safe prescribing practice. Yet, no studies have comprehensively evaluated the effectiveness of PDMP characteristics in reducing opioid-related potentially inappropriate prescribing (PIP) practices. The objective of the study is to apply machine learning methods to evaluate PDMP effectiveness by examining how different PDMP characteristics are associated with opioid-related PIPs for non-cancer chronic pain (NCCP) treatment. This was a retrospective observational study that included 802,926 adult patients who were diagnosed NCCP, obtained opioid prescriptions, and were continuously enrolled in plans of a major U.S. insurer for over a year. Four outcomes of opioid-related PIP practices, including dosage ≥50 MME/day and ≥90 MME/day, days supply ≥7 days, and benzodiazepine-opioid co-prescription were examined. Machine learning models were applied, including logistic regression, least absolute shrinkage and selection operation regression, classification and regression trees, random forests, and gradient boost modeling (GBM). The SHapley Additive exPlanations (SHAP) method was applied to interpret model results. The results show that among 1,886,146 NCCP opioid-related claims, 22.8% had an opioid dosage ≥50 MME/day and 8.9% ≥90 MME/day, 70.3% had days supply ≥7 days, and 10.3% were when benzodiazepine was filled ≤7 days ago. GBM had superior model performance. We identified the most salient PDMP characteristics that predict opioid-related PIPs (e.g., broader access to patient prescription history, monitoring Schedule IV controlled substances), which could be informative to the states considering the redesign of PDMPs.

Trends in Buprenorphine Coverage and Prior Authorization Requirements in US Commercial Formularies, 2017-2021

This cross-sectional study assesses buprenorphine coverage and prior authorization requirements in US commercial formulary data from 2017 to 2021.

Enhancing Health Equity Through Cancer Health Economics Research

Cancer displays some of the largest health-equity concerns of all diseases. This paper draws attention to how health economics research can assess strategies to reduce or even eliminate health disparities and provides pivotal examples of existing research as well as areas for future contributions. The paper also highlights critical data limitations that currently restrain the impact health economics research could have. We then explore new areas of inquiry where economic research is sparse but could have an important impact on health equity, particularly in topics involving Medicare and Medicaid policies that expand reimbursement and generosity of coverage. Health economics studies are notably absent from policies and practices surrounding clinical trials, representing an opportunity for future research. We urge health economics researchers to consider experiments, interventions, and assessments through primary data collection; we further encourage the formulation of multidisciplinary teams to ensure that health economics skills are well melded with other areas of expertise. These teams are needed to maximize novelty and rigor of evidence. As policies are promulgated to address disparities in cancer, involvement of economics in a multidisciplinary context can help ensure that these policies do not have unintended impacts that may deepen inequities.

Racial and Ethnic Disparities in Buprenorphine and Extended-Release Naltrexone Filled Prescriptions During the COVID-19 Pandemic

Importance

COVID-19 disrupted delivery of buprenorphine and naltrexone treatment for opioid use disorder (OUD), and during the pandemic, members of racial and ethnic minority groups experienced increased COVID-19 and opioid overdose risks compared with White individuals. However, whether filled buprenorphine and naltrexone prescriptions varied across racial and ethnic groups during the COVID-19 pandemic remains unknown.

Objective

To investigate whether disruptions in filled buprenorphine and naltrexone prescriptions differed by race and ethnicity and insurance status or payer type.

Design, Setting, and Participants

This cross-sectional study used retail pharmacy claims from May 2019 to June 2021 from the Symphony Health database, which includes 92% of US retail pharmacy claims, with race and ethnicity data spanning all insurance status and payer categories. Interrupted time series were used to estimate levels and trends of dispensed buprenorphine and naltrexone prescriptions before and after pandemic onset. Included individuals were those who filled buprenorphine and extended-release naltrexone prescriptions. Data were analyzed from July 2021 through March 2022.

Main Outcomes and Measures

Weekly rates of dispensed buprenorphine and extended-release naltrexone prescription fills per 1000 patients and proportion of longer (ie, ≥14 days' supply) buprenorphine prescription fills were calculated. Analyses were stratified by patient race and ethnicity and further by insurance status and payer type for White and Black patients.

Results

A total of 1 556 860 individuals who filled buprenorphine prescriptions (4359 Asian [0.3%], 94 657 Black [6.1%], 55 369 Hispanic [3.6%], and 664 779 White [42.7%]) and 127 506 individuals who filled extended-release naltrexone prescriptions (344 Asian [0.3%], 8186 Black [6.4%], 5343 Hispanic [4.2%], and 53 068 White [41.6%]) from May 6, 2019, to June 5, 2021, were analyzed. Prepandemic increases in buprenorphine fill rate flattened for all groups after COVID-19 onset (30.5 percentage point difference in trend; P < .001) compared with prepandemic trends. Significant level decreases in buprenorphine fills (ranging from 2.5% for Black patients; P = .009 to 4.0% for Hispanic patients; P = .009) at pandemic onset were observed for members of racial and ethnic minority groups but not White patients. At pandemic onset, rate of buprenorphine fills decreased in level for Medicare and cash-paying patients but with greater decreases for Black patients (Medicare: 10.0%; P < .001; cash: 20.0%; P < .001) than White patients (Medicare: 3.5%; P = .004; cash: 15.0%; P < .001). No decreases were found among Medicaid patients. Unlike buprenorphine, extended-release naltrexone had uniform level (from 10.0% for White patients with private insurance; P < .001 to 23.3% for Black patients with Medicare; P < .001) and trend (from 15.5 percentage points for White patients with Medicaid; P = .001 to 52.0 percentage points for Black patients with private insurance; P < .001) decreases across groups.

Conclusions and Relevance

This study found that the COVID-19 pandemic was associated with immediate decreases in filled buprenorphine prescriptions by members of racial and ethnic minority groups but not White individuals. These findings suggest that members of racial and ethnic minority groups had larger losses in buprenorphine access during the pandemic across payer types.

Determinants of Disparities in Early COVID-19 Job Losses

This study examines the sociodemographic divide in early labor market responses to the U.S. COVID-19 epidemic and associated policies, benchmarked against two previous recessions. Monthly Current Population Survey (CPS) data show greater declines in employment in April and May 2020 (relative to February) for Hispanic individuals, younger workers, and those with a high school diploma or some college. Between April and May, the demographic subgroups considered regained some employment. Reemployment in May was broadly proportional to the employment drop that occurred through April, except for Black individuals, who experienced a smaller rebound. Compared to the 2001 recession and the Great Recession, employment losses in the early COVID-19 recession were smaller for groups with low or high (vs. medium) education. We show that job loss was greater in occupations that require more interpersonal contact and that cannot be performed remotely, and that pre-COVID-19 sorting of workers into occupations and industries along demographic lines can explain a sizable portion of the demographic gaps in new unemployment. For example, while women suffered more job losses than men, their disproportionate pre-epidemic sorting into occupations compatible with remote work shielded them from even larger employment losses. However, substantial gaps in employment losses across groups cannot be explained by socioeconomic differences. We consider policy lessons and future research needs regarding the early labor market implications of the COVID-19 crisis.

Determinants of Disparities in Early COVID-19 Job Losses

This study examines the sociodemographic divide in early labor market responses to the U.S. COVID-19 epidemic and associated policies, benchmarked against two previous recessions. Monthly Current Population Survey (CPS) data show greater declines in employment in April and May 2020 (relative to February) for Hispanic individuals, younger workers, and those with a high school diploma or some college. Between April and May, the demographic subgroups considered regained some employment. Reemployment in May was broadly proportional to the employment drop that occurred through April, except for Black individuals, who experienced a smaller rebound. Compared to the 2001 recession and the Great Recession, employment losses in the early COVID-19 recession were smaller for groups with low or high (vs. medium) education. We show that job loss was greater in occupations that require more interpersonal contact and that cannot be performed remotely, and that pre-COVID-19 sorting of workers into occupations and industries along demographic lines can explain a sizable portion of the demographic gaps in new unemployment. For example, while women suffered more job losses than men, their disproportionate pre-epidemic sorting into occupations compatible with remote work shielded them from even larger employment losses. However, substantial gaps in employment losses across groups cannot be explained by socioeconomic differences. We consider policy lessons and future research needs regarding the early labor market implications of the COVID-19 crisis.

Dolutegravir resistance in Malawi’s national HIV treatment program

Dolutegravir HIV drug resistance (HIVDR) data from Africa remain sparse. We reviewed HIVDR results of Malawians on dolutegravir-based antiretroviral therapy (November 2020–September 2021). Of 6462 eligible clients, 33 samples were submitted to South Africa, 27 were sequenced successfully, and 8 (30%) had dolutegravir HIVDR. Malawi urgently requires adequate HIVDR testing capacity.

The Association Between Scope of Practice Regulations and Nurse Practitioner Prescribing of Buprenorphine After the 2016 Opioid Bill

This article examines the relationship between federal regulations, state scope-of-practice regulations on nurse practitioners (NPs), and buprenorphine prescribing patterns using pharmacy claims data from Optum's deidentified Clinformatics Data Mart between January 2015 and September 2018. The county-level proportion of patients filling prescriptions written by NPs was low even after the 2016 Comprehensive Addiction and Recovery Act (CARA), 2.7% in states that did not require physician oversight of NPs, and 1.1% in states that did. While analyses in rural counties showed higher rates of buprenorphine prescriptions written by NPs, rates were still considerably low: 3.7% in states with less restrictive regulations and 1.1% in other states. These results indicate that less restrictive scope-of-practice regulations are associated with greater NP prescribing following CARA. The small magnitude of the changes indicates that federal attempts to expand treatment access through CARA have been limited.

State-level regulations and opioid-related health outcomes

INTRODUCTION

Due to the ongoing opioid use disorder crisis, improved access to opioid treatment programs (OTPs) is needed. However, OTPs operate in a complex regulatory environment which may limit their ability to positively affect health outcomes. The objective of this study was to examine how the number and type of state OTP regulations are associated with opioid-related deaths, hospitalizations, and emergency department visits.

METHODS

Cross-sectional data capturing information about OTP state-level regulations collected by Jackson et al. was combined with other secondary sources. OTP regulations were categorized based on the nature of their focus. Analyses include bivariate and multivariable regressions that controlled for region and other state laws that can affect opioid outcomes.

RESULTS

In bivariate analysis, a greater number of OTP regulations was positively correlated with both deaths and emergency visits. Moreover, a greater number of regulations in the Physical Facilities Management category (e.g., rules related to restrooms, lighting, and signage) was positively correlated with both deaths and hospitalizations. The number of regulations in the Staffing Requirement category was positively associated with emergency visits. In adjusted analysis, the number of regulations in the Physical Facilities Management category was positively associated with opioid-related deaths.

CONCLUSIONS

States with a higher number of regulations had poorer opioid-related outcomes. Additional research is needed to support policy decisions that can improve access to OTPs and reduce avoidable deaths, hospitalizations, and emergency visits.

Strategic use of health information exchange and market share, payer mix, and operating margins

BACKGROUND

Health information exchange (HIE) capabilities are tied to health care organizations' strategic and business goals. As a technology that connects information from different organizations, HIE may be a source of competitive advantage and a path to improvements in performance.

PURPOSE

The aim of the study was to identify the impact of hospitals' use of HIE capabilities on outcomes that may be sensitive to changes in various contracting arrangements and referral patterns arising from improved connectivity.

METHODOLOGY

Using a panel of community hospitals in nine states, we examined the association between the number of different data types the hospital could exchange via HIE and changes in market share, payer mix, and operating margin (2010-2014). Regression models that controlled for the number of different data types shared intraorganizationally and other time-varying factors and included both hospital and time fixed effects were used for adjusted estimates of the relationships between changes in HIE capabilities and outcomes.

RESULTS

Increasing HIE capability was associated with a 13 percentage point increase in a hospital's discharges that were covered by commercial insurers or Medicare (i.e., payer mix). Conversely, increasing intraorganizational information sharing was associated with a 9.6 percentage point decrease in the percentage of discharges covered by commercial insurers or Medicare. Increasing HIE capability or intraorganizational information sharing was not associated with increased market share nor with operating margin.

CONCLUSIONS

Improving information sharing with external organizations may be an approach to support strategic business goals.

PRACTICE IMPLICATIONS

Organizations may be served by identifying ways to leverage HIE instead of focusing on intraorganizational exchange capabilities.

Marijuana liberalization policies and perinatal health

We studied the effect of marijuana liberalization policies on perinatal health with a multiperiod difference-in-differences estimator that exploited variation in effective dates of medical marijuana laws (MML) and recreational marijuana laws (RML). We found that the proportion of maternal hospitalizations with marijuana use disorder increased by 23% (0.3 percentage points) in the first three years after RML implementation, with larger effects in states authorizing commercial sales of marijuana. This growth was accompanied by a 7% (0.4 percentage points) decline in tobacco use disorder hospitalizations, yielding a net zero effect over all substance use disorder hospitalizations. RMLs were not associated with statistically significant changes in newborn health. MMLs had no statistically significant effect on maternal substance use disorder hospitalizations nor on newborn health and fairly small effects could be ruled out. In absolute numbers, our findings implied modest or no adverse effects of marijuana liberalization policies on the array of perinatal outcomes considered.

Long-term opioid therapy tapering: Trends from 2014 to 2018 in a Midwestern State

BACKGROUND

The 2016 Centers for Disease Control and Prevention guideline for prescribing opioids for chronic pain (Guideline hereafter) emphasized tapering patients from long-term opioid therapy (LTOT) when the harms outweigh the benefits.

METHODS

To examine tapering from LTOT before and after the Guideline release, we conducted a retrospective cohort study of adults with high-dose LTOT (mean of >50 Morphine Milligram Equivalents [MME]/day) from 2014 to 2018 from one Midwest state's Health Information Exchange. We identified tapering (dose reductions in mean MME/day greater than 15%, 30%, 50%) and rapid discontinuation episodes (reduction to zero MME/day) over a 6-month follow-up period relative to a 3-month baseline period. We used segmented regressions to estimate outcomes adjusted for time trends and relevant state laws limiting opioid prescribing.

RESULTS

The Guideline release was associated with statistically significant immediate increase in the patient likelihood of experiencing tapering (15%: 1.8% point [95% confidence interval (CI): 1.2-2.6; 30%: 1.4% point, 95% CI: 0.7-2.2; 50%: 0.8% point, 95% CI: 0.2-1.4) and rapid discontinuation episodes (0.006% point, 95% CI: 0.001-0.01). After the Guideline release, the patient likelihood of tapering increased over time (15%: 0.4% point/month, 95% CI: 0.3-0.5; 30%: 0.3% point/month, 95% CI:0.2-0.4; 50%: 0.3% point/month, 95% CI: 0.2-0.3; rapid discontinuation: 0.01% point/month, 95% CI: 0.007-0.01). Tapering and rapid discontinuation trends was similar among gender and race categories.

CONCLUSION

The Guideline may be a useful tool in altering opioid prescribing practices, particularly for patients on shorter durations of LTOT.

Users of retail medications for opioid use disorders faced high out-of-pocket prescription spending in 2011-2017

INTRODUCTION

High out-of-pocket spending has been a barrier to treatment for the estimated 2.0 million Americans suffering from opioid use disorders (OUD). This paper provides national estimates of financial costs faced by the population receiving retail medications for OUD (MOUD).

METHODS

We used pooled annual data from the 2011-2017 Medical Expenditure Panel Survey (MEPS), a nationally representative sample of the civilian noninstitutionalized population in the United States. The sample includes individuals who reported filling a retail prescription for buprenorphine or naltrexone, the two most common medications available from retail pharmacies to treat OUD. The main outcome is out-of-pocket spending of retail MOUD prescriptions per fill and per person.

RESULTS

Patients with retail MOUD prescriptions spent 3.4 times more out-of-pocket for prescriptions on average than the rest of the U.S. population, with 18.8% of this population paying entirely out-of-pocket for their MOUD prescriptions. Insurance coverage is associated with reduced annual out-of-pocket MOUD expenditures between $316 and $328 per year.

CONCLUSIONS

Future policies that expand insurance and address out-of-pocket spending on MOUD could increase access to medications among individuals with OUD.

The impact of Medicaid expansion on emergency department wait times

OBJECTIVE

To estimate the impact of Medicaid expansion on emergency department (ED) wait times.

DATA SOURCES

We used 2012-2017 hospital-level secondary data from the CMS Hospital Compare data warehouse.

STUDY DESIGN

We used a state-level difference-in-differences approach to identify the impact of Medicaid expansion on four measures of ED wait times: time before being seen by a provider; time before being sent home after being seen by a provider; boarding time spent in the ED waiting to be discharged to an inpatient room; and the percentage of patients who left without being seen. We compared outcomes in states that expanded Medicaid with those in states that did not expand Medicaid.

DATA COLLECTION/EXTRACTION METHODS

Our sample included all US acute care hospitals with EDs in states that did not ever expand Medicaid or that fully expanded Medicaid in January of 2014.

PRINCIPAL FINDINGS

Medicaid expansion was associated with a 3.1-min increase (SE: 0.994, baseline mean: 30.8 min) in the time spent waiting to see an ED provider, a relative increase of 10%. Patients who were eventually sent home after being seen by a provider experienced a 7.5-min increase (SE: 1.8, baseline mean 142.1 min) in wait time. Boarding time rose by 3.8 min (SE 1.9, baseline mean 111.4 min). The percentage of patients who left without being seen rose by 0.3 percentage points (SE: 0.09, baseline mean 2.0), a relative increase of 15.3%.

CONCLUSIONS

This study provides multistate evidence that Medicaid expansion increased ED wait times for patients, indicating that ED crowding may have worsened post-expansion. Future work should aim to uncover the mechanisms through which insurance expansion increased ED wait times to provide policy direction.

US Trends in COVID-19-Associated Hospitalization and Mortality Rates Before and After Reopening Economies

Importance

After abrupt closures of businesses and public gatherings in the US in late spring 2020 due to the COVID-19 pandemic, by mid-May 2020, most states reopened their economies. Owing in part to a lack of earlier data, there was little evidence on whether state reopening policies influenced important pandemic outcomes-COVID-19-related hospitalizations and mortality-to guide future decision-making in the remainder of this and future pandemics.

Objective

To investigate changes in COVID-19-related hospitalizations and mortality trends after reopening of US state economies.

Design Setting and Participants

Using an interrupted time series approach, this cross-sectional study examined trends in per-capita COVID-19-related hospitalizations and deaths before and after state reopenings between April 16 and July 31, 2020. Daily state-level data from the University of Minnesota COVID-19 Hospitalization Tracking Project on COVID-19-related hospitalizations and deaths across 47 states were used in the analysis.

Exposures

Dates that states reopened their economies.

Main Outcomes and Measures

State-day observations of COVID-19-related hospitalizations and COVID-19-related new deaths per 100 000 people.

Results

The study included 3686 state-day observations of hospitalizations and 3945 state-day observations of deaths. On the day of reopening, the mean number of hospitalizations per 100 000 people was 17.69 (95% CI, 12.54-22.84) and the mean number of daily new deaths per 100 000 people was 0.395 (95% CI, 0.255-0.536). Both outcomes displayed flat trends before reopening, but they started trending upward thereafter. Relative to the hospitalizations trend in the period before state reopenings, the postperiod trend was higher by 1.607 per 100 000 people (95% CI, 0.203-3.011; P = .03). This estimate implied that nationwide reopenings were associated with 5319 additional people hospitalized for COVID-19 each day. The trend in new deaths after reopening was also positive (0.0376 per 100 000 people; 95% CI, 0.0038-0.0715; P = .03), but the change in mortality trend was not significant (0.0443; 95% CI, -0.0048 to 0.0933; P = .08).

Conclusions and Relevance

In this cross-sectional study conducted over a 3.5-month period across 47 US states, data on the association of hospitalizations and mortality with state reopening policies may provide input to state projections of the pandemic as policy makers continue to balance public health protections with sustaining economic activity.

Where did the specialty behavioral health workforce grow between 2011 and 2019? Evidence from census data

IMPORTANCE

Given that mental health and substance use conditions are ongoing major public health problems in the United States, it is important for researchers to understand the behavioral health treatment workforce landscape and to assess whether increases in treatment capacity exist in areas with public health needs.

OBJECTIVES

This study quantified national and county-level changes in specialty behavioral health (SBH) workforce outcomes and assessed associations between these measures and age-adjusted drug mortality rate.

DESIGN

Using a novel longitudinal dataset from the U.S. Census Bureau, this study described SBH workforce outcomes in 3130 U.S. counties between 2011 and 2019. The study stratified workforce outcomes, including the number of establishments, likelihood of having establishments, mean number of workers, and average wage of workers per county, by service settings: outpatient, residential, and hospital. The study fitted outcome data at the county level to ordinary least squares regression models as a function of the country's previous year age-adjusted drug mortality rate and county sociodemographic characteristics.

RESULTS

The number of SBH establishments, their workforce, and their wages have increased steadily between 2011 and 2019, with the largest increases occurring in the following settings: outpatient (number of establishments and employment) and residential (average wage). County-level growth of residential SBH establishments was positively and significantly associated with the county's previous year county age-adjusted drug mortality rate. We did not observe a similar positive association between either employment or wages and the mortality rate.

CONCLUSIONS

The increase in the number of SBH establishments in recent years may indicate that the SBH workforce is responding to increased need for treatment; however, more work needs to be done to close behavioral health workforce gaps in areas with an elevated drug overdose mortality rate.

How Much Do Outside Options Matter? The Effect of Subsidized Health Insurance on Social Security Disability Insurance Benefit Receipt

New government health insurance programs may affect participation in existing safety-net benefits that provide health insurance as a secondary aim. We examine whether the outside options for health insurance made available by the Affordable Care Act affected Social Security Disability Insurance (DI) application decisions. Using the universe of U.S. individual income tax records spanning 2007-2016, we first estimate the effect of Medicaid expansions using a state difference-in-differences identification strategy, but find small and statistically insignificant estimates. However, when we estimate the effect of being eligible for high vs. low Marketplace subsidies based on geography, we find some evidence consistent with subsidies increasing DI claiming among those with prior access to Employer Sponsored Insurance, and decreasing DI claiming otherwise. Overall, we find suggestive evidence that outside options for health insurance do matter, though magnitudes are small and results are statistically precise only for Marketplace coverage.

Can policy affect initiation of addictive substance use? Evidence from opioid prescribing

Drug control policy can have unintended consequences by pushing existing users to alternative, possibly more dangerous substances. Policies that target only new users may therefore be especially promising. Using commercial insurance claims data, we provide the first evidence on a set of new policies intended to reduce opioid initiation in the form of limits on initial prescription length. We also provide the first evidence on the impact of must-access prescription drug monitoring programs (MA-PDMPs), laws that do not target new users, on initial opioid use. Although initial limit policies reduce the average length of initial prescriptions, they do so primarily by raising the frequency of short prescriptions, resulting in increases in opioids dispensed to new users. In contrast, we find that MA-PDMPs reduce opioids dispensed to new users, even though they do not explicitly set out to do so. Neither policy significantly affects extreme use such as doctor shopping among new patients, because such behavior is very rare.

Health systems' use of enterprise health information exchange vs single electronic health record vendor environments and unplanned readmissions

OBJECTIVE

Enterprise health information exchange (HIE) and a single electronic health record (EHR) vendor solution are 2 information exchange approaches to improve performance and increase the quality of care. This study sought to determine the association between adoption of enterprise HIE vs a single vendor environment and changes in unplanned readmissions.

MATERIALS AND METHODS

The association between unplanned 30-day readmissions among adult patients and adoption of enterprise HIE or a single vendor environment was measured in a panel of 211 system-member hospitals from 2010 through 2014 using fixed-effects regression models. Sample hospitals were members of health systems in 7 states. Enterprise HIE was defined as self-reported ability to exchange information with other members of the same health system who used different EHR vendors. A single EHR vendor environment reported exchanging information with other health system members, but all using the same EHR vendor.

RESULTS

Enterprise HIE adoption was more common among the study sample than EHR (75% vs 24%). However, adoption of a single EHR vendor environment was associated with a 0.8% reduction in the probability of a readmission within 30 days of discharge. The estimated impact of adopting an enterprise HIE strategy on readmissions was smaller and not statically significant.

CONCLUSION

Reductions in the probability of an unplanned readmission after a hospital adopts a single vendor environment suggests that HIE technologies can better support the aim of higher quality care. Additionally, health systems may benefit more from a single vendor environment approach than attempting to foster exchange across multiple EHR vendors.

Is Healthcare Employment Resilient and “Recession Proof”?

Conventional wisdom often holds that the healthcare sector fares better than other sectors during economic downturns. However, little research has examined the relationship between local economic conditions and healthcare employment. Understanding how the healthcare sector responds to economic conditions is important for policymakers seeking to ensure an adequate supply of healthcare workers, as well as for those directing displaced workers into new jobs. We examine the impact of macroeconomic conditions on both the healthcare labor market and the pipeline of healthcare workers receiving healthcare degrees during 2005–2017 (the pre-COVID era). Our results indicate that the healthcare sector is stable across past business cycles. If anything, when areas experience more severe local economic downturns, healthcare employment increases. Much remains unknown about how the healthcare sector will fare during the current recession. Our study represents an important backdrop as policymakers consider ways to sustain the healthcare sector during current economic and public health turbulence.

Levels of Employment and Community Engagement among Low-Income Adults: Implications for Medicaid Work Requirements

CONTEXT

Twenty states are pursuing community engagement requirements ("work requirements") in Medicaid, though legal challenges are ongoing. While most nondisabled low-income individuals work, it is less clear how many engage in the required number of hours of qualifying community engagement activities and what heterogeneity may exist by race/ethnicity, age, and gender. The authors' objective was to estimate current levels of employment and other community engagement activities among potential Medicaid beneficiaries.

METHODS

The authors analyzed the US Census Bureau's national time-use survey data for the years 2015 through 2018. Their main sample consisted of nondisabled adults between 19 and 64 years with family incomes less than 138% of the federal poverty level (N = 2,551).

FINDINGS

Nationally, low-income adults who might become subject to Medicaid work requirements already spent an average of 30 hours per week on community engagement activities. However, 22% of the low-income population-particularly women, older adults, and those with less education-would not currently satisfy a 20-hour-per-week requirement.

CONCLUSIONS

Although the majority of potential Medicaid beneficiaries already meet community engagement requirements or are exempt, 22% would not currently satisfy a 20-hour-per-week requirement and therefore could be at risk for losing coverage.

ACA Medicaid Expansion Associated With Increased Medicaid Participation and Improved Health Among Near-Elderly: Evidence From the Health and Retirement Study

The Affordable Care Act (ACA) dramatically expanded health insurance, but questions remain regarding its effects on health. We focus on older adults for whom health insurance has greater potential to improve health and well-being because of their greater health care needs relative to younger adults. We further focus on low-income adults who were the target of the Medicaid expansion. We believe our study provides the first evidence of the health-related effects of ACA Medicaid expansion using the Health and Retirement Study (HRS). Using geo-coded data from 2010 to 2016, we estimate difference-in-differences models, comparing changes in outcomes before and after the Medicaid expansion in treatment and control states among a sample of over 3,000 unique adults aged 50 to 64 with income below 100% of the federal poverty level. The HRS allows us to examine morbidity outcomes not available in administrative data, providing evidence of the mechanisms underlying emerging evidence of mortality reductions due to expanded insurance coverage among the near-elderly. We find that the Medicaid expansion was associated with a 15 percentage point increase in Medicaid coverage which was largely offset by declines in other types of insurance. We find improvements in several measures of health including a 12% reduction in metabolic syndrome; a 32% reduction in complications from metabolic syndrome; an 18% reduction in the likelihood of gross motor skills difficulties; and a 34% reduction in compromised activities of daily living (ADLs). Our results thus suggest that the Medicaid expansion led to improved physical health for low-income, older adults.

Same Game, Different Names: Cream-Skimming in the Post-ACA Individual Health Insurance Market

One of the Affordable Care Act’s (ACA) signature reforms was creating centralized Health Insurance Marketplaces to offer comprehensive coverage in the form of comprehensive insurance complying with the ACA’s coverage standards. Yet, even after the ACA’s implementation, millions of people were covered through noncompliant plans, primarily in the form of continued enrollment in “grandmothered” and “grandfathered” plans that predated ACA’s full implementation and were allowed under federal and state regulations. Newly proposed and enacted federal legislation may grow the noncompliant segment in future years, and the employment losses of 2020 may grow reliance on individual market coverage further. These factors make it important to understand how the noncompliant segment affects the compliant segment, including the Marketplaces. We show, first, that the noncompliant segment of the individual insurance market substantially outperformed the compliant segment, charging lower premiums but with vastly lower costs, suggesting that insurers have a strong incentive to enter the noncompliant segment. We show, next, that state’s decisions to allow grandmothered plans is associated with stronger financial performance of the noncompliant market, but weaker performance of the compliant segment, as noncompliant plans attract lower-cost enrollees. This finding indicates important linkages between the noncompliant and compliant segments and highlights the role state policy can play in the individual insurance market. Taken together, our results point to substantial cream-skimming, with noncompliant plans enrolling the healthiest enrollees, resulting in higher average claims cost in the compliant segment.

Characterizing variability in state-level regulations governing opioid treatment programs

INTRODUCTION

The opioid use crisis has left nearly 1 million people in need of treatment. States have focused primarily on policies aimed at decreasing the prevalence of opioid use disorder. However, opioid treatment programs (OTPs), an evidence-based modality which can prevent and decrease opioid-related mortality and morbidity, remain highly complex with variation in treatment by state. Evidence-based state-level regulation of OTPs can be a powerful tool and may help improve the unmet need for treatment. This study characterized the variability in state laws that regulate OTPs and examines how this variability is associated with state characteristics. Our data provides an opportunity for policymakers to consider regulations that increase access to care and retention in OTPs, which could improve population health.

MATERIALS AND METHODS

Utilizing policy mapping techniques, we identified all regulations governing OTPs in effect on January 1, 2017 and determined whether the most common regulations were consistent with best practices. We then examined how the number and type of regulations were associated with state characteristics. All policy mapping research was conducted between November 2017 and March 2019.

RESULTS

We identified 89 different regulations, the most common of which exists in fewer than half of all states; and most exist in <25% of states. Eighteen of the 30 most common regulations were inconsistent with best practice recommendations. Overall, variability in the number and type of OTP regulations was related to geographic location as opposed to state size.

CONCLUSIONS

Wide-ranging variability exists in the regulations of OTPs across the U.S. Most state OTP regulations are not congruent with best practices.

Serum betatrophin and irisin levels in hepatocellular carcinoma

Hepatocellular carcinoma (HCC) development is a complex process with well-known risk factors, however the role of betatrophin/angiopoietin-like protein 8 and irisin has been poorly investigated thus far. The aim of this study is to measure betatrophin and irisin serum levels in HCC, cirrhotic patients and controls, assess their relationship with cancer etiology and grade, metabolic abnormalities and liver dysfunction severity. Serum betatrophin and irisin concentrations were measured with commercially available ELISA kits in 69 cirrhotic patients with HCC, 24 patients with non-viral cirrhosis and 20 healthy volunteers. The severity of liver disfunction was assessed according to Child-Pugh (C-P) score, while HCC grade according to the Barcelona clinic liver cancer (BCLC) staging system. Serum betatrophin concentration was significantly higher (33.7 ± 13.4 versus 12.3 ± 2.0 ng/ml; P < 0.001), while serum irisin level significantly lower in HCC patients compared to controls (2.52 ± 1.14 versus 4.46 ± 1.34 μg/ml; P = 0.02). Betatrophin level was also significantly elevated among cirrhotic patients compared to healthy volunteers. More evident serum betatrophin increase was found in patients with viral disease (34.8 ± 12.9 versus 26.1 ± 13.8 ng/ml; P < 0.001). Serum irisin concentration was significantly decreased in more advanced HCC cases (stage A versus C according to BCLC: 3.4 ± 1.3 versus 1.89 ± 1.1 μg/ml; P = 0.02). Decline of serum irisin (A: 3.4 ± 1.2; B: 2.42 ± 0.8; C: 1.91 ± 1.19 μg/ml; P = 0.03) and up-regulation of serum betatrophin levels (A: 24.1 ± 13.8; B: 39.3 ± 11.4; C: 46.2 ± 9.4 ng/ml; P = 0.03) were observed in patients with more advanced cirrhosis according to C-P score. We concluded that betatrophin serum level increased in cirrhotic patients, compared to controls. Since there was no difference between cirrhotic patients with and without intercurrent HCC, we suppose it may have an influence on fibrosis development, however not hepatocarcinogensis. Irisin serum level decreased in HCC patients, especially with more advanced disease grade, and was inversely related to the severity of liver disfunction.