Contraception claims by medication for opioid use disorder prescription status among insured women with opioid use disorder, United States, 2018

OBJECTIVE(S)

To understand how contraception method use differed between women prescribed and not prescribed medications for opioid use disorder (MOUD) among commercially-insured and Medicaid-insured women.

STUDY DESIGN

IBM Watson Health MarketScan Commercial Claims and Encounters database and the Multi-State Medicaid database were used to calculate the (1) crude prevalence, and (2) adjusted odds ratios (adjusted for demographic characteristics) of using long-acting reversible or short-acting hormonal contraception methods or female sterilization compared with none of these methods (no method) in 2018 by MOUD status among women with OUD, aged 20 to 49 years, with continuous health insurance coverage through commercial insurance or Medicaid for ≥6 years. Claims data was used to define contraception use. Fisher exact test or χ² test with a P-value ≤ 0.0001, based on the Holm-Bonferroni method, and 95% confidence intervals were used to determine statistically significant differences for prevalence estimates and adjusted odds ratios, respectively.

RESULTS

Only 41% of commercially-insured and Medicaid-insured women with OUD were prescribed MOUD. Medicaid-insured women with OUD prescribed MOUD had a significantly lower crude prevalence of using no method (71.1% vs 79.0%) and higher odds of using female sterilization (aOR, 1.33; 95% CI: 1.06-1.67 vs no method) than those not prescribed MOUD. Among commercially-insured women there were no differences in contraceptive use by MOUD status and 66% used no method.

CONCLUSIONS

Among women with ≥ 6 years of continuous insurance coverage, contraceptive use differed by MOUD status and insurance. Prescribing MOUD for women with OUD can be improved to ensure quality care.

IMPLICATIONS

Only two in five women with OUD had evidence of being prescribed MOUD, and majority did not use prescription contraception or female sterilization. Our findings support opportunities to improve prescribing for MOUD and integrate contraception and MOUD services to improve clinical care among women with OUD.

Racial Differences in Prevalence and Treatment for Psoriatic Arthritis and Ankylosing Spondylitis by Insurance Coverage in the USA

INTRODUCTION

Patients with psoriatic arthritis (PsA) and ankylosing spondylitis (AS) may receive suboptimal care, and differences in care by race/ethnicity, sex, and insurance coverage are not well studied.

METHODS

This was a descriptive, retrospective cross-sectional US claims database analysis utilizing the Medicaid multi-state segment of the IBM® MarketScan® Commercial Claims and Encounters Supplemental Database and Optum Insight Clinformatics® Data Mart database for 2019. Patients aged ≥ 18 years with PsA or AS and continuous medical and pharmacy coverage were included. Outcomes evaluated were prevalence and percentage of patients receiving biologic disease-modifying antirheumatic drugs (bDMARDs)/targeted synthetic DMARDs (tsDMARDs) or visiting a rheumatologist. Outcomes were stratified by race/ethnicity, sex, and insurance coverage, with outcomes determined for commercial insurance, Medicare, and Medicaid enrollees. Differences observed in outcomes were numerical in nature.

RESULTS

Prevalences of PsA and AS were highest for Medicare enrollees (320 and 156 per 100,000 persons [0.32 and 0.16%], respectively) and lowest for Medicaid enrollees (132 and 71 per 100,000 persons [0.13 and 0.07%], respectively). White patients had the greatest prevalence versus patients of other races/ethnicities. Females had a higher prevalence of PsA than males, while AS prevalence was generally lower for females versus males for each insurance category. The percentage of patients prescribed bDMARDs/tsDMARDs was highest for commercial insurance enrollees (PsA 63%, AS 43%) and lowest for Medicare enrollees (PsA 21%, AS 11%). The proportion of patients who saw a rheumatologist was lower for Medicaid enrollees (PsA 12%, AS 10%) than for commercial insurance or Medicare enrollees (PsA 68%, 55%; AS 67%, 42%). For commercial insurance and Medicare enrollees, the percentage of patients visiting a rheumatologist was similar by race/ethnicity but higher for females versus males.

CONCLUSIONS

The prevalence and treatment of PsA and AS differs by race/ethnicity, insurance coverage, and sex in the USA. Efforts for improving access to care are needed to improve outcomes among all patients.

Patterns of patient discontinuation from buprenorphine/naloxone treatment for opioid use disorder: A study of a commercially insured population in Massachusetts

BACKGROUND

Research has shown buprenorphine/naloxone to be an effective medication for treating individuals with opioid use disorder. At the same time, treatment discontinuation rates are reportedly high though much of the extant evidence comes from studies of the Medicaid population.

OBJECTIVES

To examine the pattern and determinants of buprenorphine/naloxone treatment discontinuation in a population of commercially insured individuals.

RESEARCH DESIGN

We performed a retrospective observational analysis of Massachusetts All Payer Claims Data (MA APCD) covering years 2013 through 2017. We defined treatment discontinuation as a gap of 60 consecutive days without a prescription for buprenorphine/naloxone within a time frame of 24 months from the initiation of treatment. A mixed-effect Cox proportional hazard model examined the associated risk of discontinuing treatment with baseline predictors.

SUBJECTS

A total of 5134 individuals who were commercially insured during the study period.

MEASURES

Buprenorphine/naloxone treatment discontinuation.

RESULTS

Overall 75% of individuals had discontinued treatment within two years of initiating treatment, and median time to discontinuation was 300 days. Patients aged between 18 and 24 years (HR = 1.436, 95%, CI = 1.240-1.663) and receiving treatment from prescribers with high panel-size (HR = 1.278, 95% CI = 1.112-1.468) had higher risk of discontinuing treatment. On the contrary, patients receiving treatment from multiple prescribers had lower associated risk of treatment discontinuation.

CONCLUSIONS

A substantial percentage of patients discontinue treatment well before they can typically meet criteria for sustained remission. Further investigations should assess the clinical outcomes following premature discontinuation and identify strategies for retaining patients in treatment.

Commercial and public payer opioid analgesic prescribing policies: a case study

Background

One strategy to address the high number of U.S. opioid-related deaths is to restrict high-risk or inappropriate opioid analgesic prescribing and dispensing. Federal and state laws and regulations have implemented restrictions but less is known about commercial and public payers’ policies aside from clinician anecdotal reports that these policies are increasing. To assess the number and types of policies with temporal trends, we examined commercial and public (Medicaid) payer policies in one state, Michigan, that has high opioid-related deaths and implemented opioid analgesic prescribing laws.

Methods

Policies for seven large commercial payers and the public payer for 2012–2018 were reviewed and categorized by actions. Joinpoint regression was used to summarize temporal trends on number of policies for all payers and subgroups.

Results

Across the 7 years, there were 529 action policies (75.57 (95% confidence intervals (CI) 35.93, 115.22) actions per year) with a range of 36 to 103 actions by payer. Limitations on number of days for initial prescriptions and prior authorizations were the most frequently implemented policy. The temporal trend showed a decline in new policies from 2012 to 2013 but a steady increase from 2014 to 2018 (average annual percent change or AAPC=29.6% (95% confidence intervals 13.2, 48.5%)). The public payer (n=47 policies) showed no increase in number of policies over time (AAPC=2.9% (95% CI -41.6, 61.6%).

Conclusions

The eight commercial and public payers implemented many new policies to restrict opioid analgesic prescribing with a steady increase in the number of such policies implemented from 2014 to 2018. This case study documented that at least in one state with high opioid-related deaths and multiple commercial payers, new and different policies were increasingly implemented creating barriers to patient care. The impact of these policies is understudied, complicating recommendation of best practices.

Osteoporotic fracture trends in a population of US managed care enrollees from 2007 to 2017

This study expands on previous findings that hip fracture rates may no longer be declining. We found that age- and sex-adjusted fracture rates in the US plateaued or increased through mid-2017 in a population of commercially insured and Medicare Advantage health plan enrollees, in contrast to a decline from 2007 to 2013.

INTRODUCTION

The purpose of this study was to evaluate fracture trends in US commercial and Medicare Advantage health plan members aged ≥ 50 years between 2007 and 2017.

METHODS

Retrospective analysis of the Optum Research Database from January 1, 2007, to May 31, 2017.

RESULTS

Of 1,841,263 patients identified with an index fracture, 930,690 were case-qualifying and included in this analysis. The overall age- and sex-adjusted fracture rate decreased from 14.67/1000 person-years (py) in 2007 to 11.79/1000 py in 2013, followed by a plateau for the next 3 years and then an increase to 12.50/1000 py in mid-2017. In females aged ≥ 65 years, fracture rates declined from 27.49/1000 py in 2007 to 22.08/1000 py in 2013, then increased to 24.92/1000 py in mid-2017. Likewise, fracture rates in males aged ≥ 65 years declined from 2007 (12.00/1000 py) to 2013 (10.72/1000 py), then increased to 12.04/1000 py in mid-2017. The age- and sex-adjusted fracture rates for most fracture sites declined from 2007 to 2013 by 3.7% per year (P = 0.310).

CONCLUSIONS

Following a consistent decline in fracture rate from 2007 to 2013, trends from 2014 to 2017 indicate fracture rates are no longer declining and, for some fracture types, rates are rising.

Factors Associated With the Cost of Care for the Most Common Atraumatic Painful Upper Extremity Conditions

PURPOSE

To help strategize efforts to optimize value (relative improvement in health for resources invested), we analyzed the factors associated with the cost of care and use of resources for painful, nontraumatic conditions of the upper extremity.

METHODS

The following were the most common upper extremity diagnoses in the Truven Health MarketScan database: shoulder pain and rotator cuff tendinopathy, shoulder stiffness, shoulder arthritis, lateral epicondylitis, hand arthritis, trigger finger, wrist pain, and hand pain. Multivariable generalized linear regression models were constructed accounting for sex, age, employment status, enrollment year, payer type, emergency room visit, joint injection, magnetic resonance imaging (MRI), physical or occupational therapy, outpatient and inpatient surgery, and insurance type. In addition, we assessed the use of the following 4 diagnostic and treatment interventions: joint injection, surgery, MRI, and physical or occupational therapy.

RESULTS

Inpatient and outpatient surgery are the largest contributors to the total amount paid for most diagnoses. Older patients had more injections for the majority of conditions.

CONCLUSIONS

Efforts to improve the value of care for nontraumatic upper extremity pain can focus on the relative benefits of surgery compared with other treatments and interventions to lower the costs of surgery (eg, office surgery and limited draping for minor hand surgery).

TYPE OF STUDY/LEVEL OF EVIDENCE

Economic II.

Association between cannabis laws and opioid prescriptions among privately insured adults in the US

We examine the association between opioid prescription patterns in privately insured adults and changes in state cannabis laws among five age groups (18-25, 26-35 36-45, 46-55 and 56-64 years). Using the 2016 Clinformatics Data Mart, a nationwide commercial health insurance database, we performed a cross-sectional analysis of two types of opioid prescribing (>30-day and >90-day prescriptions) among all adults aged 18-64 based on the stringency of cannabis laws. We found a significant interaction between age and cannabis law on opioid prescriptions. Age-stratified multilevel multivariable analyses showed lower opioid prescription rates in the four younger age groups only in states with medical cannabis laws, when considering both >30 day and >90 day opioid use [>30 day adjusted odds ratio (aOR) = 0.56, in 18-25, aOR = 0.67 in 26-35, aOR = 0.67 in 36-45, and aOR = 0.76 in 46-54 years; >90 day aOR = 0.56, in 18-25, aOR = 0.68 in 26-35, aOR = 0.69 in 36-45, and aOR = 0.77 in 46-54 years, P < 0.0001 for all]. This association was not significant in the oldest age group of 55-64 years. There was no significant association between opioid prescriptions and other categories of cannabis laws (recreational use and decriminalization) in any of the age groups studied.

The impact of high school athletic trainer services on medical payments and utilizations: a microsimulation analysis on medical claims

Background

Increasing athletic trainer (AT) services in high schools has attracted widespread interest across the nation as an effective instrument to manage injuries and improve children’s health, but there is a lack of evidence on potential medical savings. Our study aimed to address this knowledge gap and provide evidence of AT impacts on medical payments and utilizations to inform public policy decision.

Methods

We obtained medical claims of patients aged 14 to 18 years from the 2011–2014 Oregon All Payer All Claims limited dataset. We calculated payer payments and utilizations for medical claims under AT’s scope of practice. We used zip codes to link patients with the enrollment boundaries of Oregon public high schools, which were classified as either “AT group” or “non-AT group”. We implemented an innovative microsimulation analysis to address the uncertainty of linkage between children and schools.

Results

Our analysis included 64,115 and 84,968 eligible children with Medicaid and commercial insurance, respectively. Associated with high school AT services, Medicaid saved an average of $64 per patient during the study period, while commercial insurance payment rarely changed. AT services may reduce emergency visits for both insurance types but increase total visits for commercially insured patients.

Conclusions

Our study provides evidence for the differential impacts of AT services on medical payments and utilizations. The legislators should consider to allocate funds for high schools to directly employ ATs. This will encourage ATs to work to their highest ability to improve children’s wellbeing while containing avoidable medical cost.

Burden of illness in patients with possible Lennox-Gastaut syndrome: A retrospective claims-based study

OBJECTIVE

Lennox-Gastaut syndrome (LGS) is a severe and treatment-resistant epilepsy syndrome characterized by multiple subtypes of intractable seizures, moderate to severe cognitive impairment, and slow spike-wave complexes on electroencephalographic (EEG) recordings. Lennox-Gastaut syndrome is also associated with increased risk for injury, reduced quality of life, long-term disability, and early mortality. By evaluating private and public US medical insurance claims, we quantified healthcare utilization and direct costs in patients with possible LGS.

METHODS

Commercial and Medicaid insurance claims (Truven Health Analytics) from October 2010 to September 2015 were queried to identify patients with intractable epilepsy, intellectual disability, ≥1 prescription for selected antiepileptic drugs (AEDs), and ≥2 years of continuous enrollment. To identify patients with LGS in the absence of a specific International Classification of Diseases ICD-9 diagnosis code, current or prior rufinamide use was selected as a disease indicator of LGS per previously published methodology. Characteristics significantly predictive of rufinamide use were identified with multivariate regression by comparing groups with and without LGS, then assessed in non-rufinamide users fulfilling all other inclusion criteria. Controls without epilepsy, seizures, or prescriptions for selected AEDs were matched to patients with possible LGS by age, gender, US region, and dates of insurance coverage. Average healthcare utilization and costs per patient per year (PPPY) were evaluated for a 2-year postindex period and compared between the cohort with LGS and controls by insurance type. Costs were normalized to 2017 dollars at 3% per annum.

RESULTS

In the study, 6019 patients with possible LGS (53% male, mean age of 13 years, in both insurance groups) were identified: 2270 with commercial insurance and 3749 with Medicaid. The cohort with LGS used >8 times more services and >7 times more drugs than controls (all p < 0.001) in both insurance groups. The biggest contributors to service use PPPY were outpatient physician visits and home health services in the commercial-insured cohort with LGS and other outpatient visits and home health services in the Medicaid-insured cohort with LGS. Average total costs PPPY (services + drugs) were significantly higher for the cohort with LGS vs. controls: $65,026 (SD $34,324) vs. $2442 (SD $10,670) for commercial-insured and $63,930 (SD $45,761) vs. $3849 (SD $13849) for Medicaid-insured patients. The biggest cost contributors PPPY were inpatient care in the commercial-insured cohort with LGS and home health services in the Medicaid-insured cohort with LGS.

CONCLUSIONS

Patients with possible LGS have significantly higher healthcare utilization and costs than patients without epilepsy or seizures. Our results suggest that direct costs associated with LGS are substantial and highlight the need for new and effective treatments.

The Mental Health Parity and Addiction Equity Act (MHPAEA) evaluation study: Did parity differentially affect substance use disorder and mental health benefits offered by behavioral healthcare carve-out and carve-in plans?

BACKGROUND

To assess whether implementation of the Mental Health Parity and Addiction Equity Act (MHPAEA) was associated with: 1. Reduced differences in financial requirements (i.e., copayments and coinsurance) for substance use disorder (SUD) versus specialty mental health (MH) care and 2. Reductions in the level of cost-sharing for SUD-specific services.

METHODS

MH and SUD copayments and coinsurance, 2008-2013, were obtained from benefits databases for carve-in and carve-out plans from Optum®. Linear regression was used to estimate the association of MHPAEA with differences between MH and SUD care financial requirements among carve-in and carve-out plans. A two-part regression model investigated whether MHPAEA was associated with changes in the use or level of financial requirements for SUD-specific services among carve-out plans.

RESULTS

MHPAEA was not associated with significant changes in the difference between SUD and MH copayments or coinsurance levels among either carve-in or carve-out plans. MHPAEA was associated with decreases in the levels of inpatient (in-network: -$51.17; out-of-network: -$34.39) and outpatient (in-network: -$10.26) detox copayments, but increases in the levels of in-network outpatient detox coinsurance (6 percentage points) among all carve-out plans.

CONCLUSION

Even if SUD benefits had been historically less generous than MH benefits, SUD financial requirements were already at parity with MH financial requirements by the time MHPAEA was passed, among Optum® plans. MHPAEA's SUD parity mandate reduced cost-sharing for detox services via copayments, but, for outpatient detox, the law simultaneously increased cost-sharing via coinsurance.

Preparing for an "Insured" Old Age: Insurance Purchase and Self-Support in Old Age in Rural China

This article explores an emerging trend among young and middle-aged rural couples in Northeast China who have purchased recently marketized commercial insurance as a way to prepare for self-support in old age. It discusses how the commercial insurance industry has created a rural elder-care market among a population that traditionally relied on family for support in old age. It also delves into the ways in which the transformations of intergenerational exchange and family structure and a lack of health care access have contributed to the preparation for self-support in old age and have thus fostered the creation of a rural elder-care market for the insurance industry. This emerging trend reveals a transition from traditional family support to a combination of multiple ways of elder care, in particular self-support in old age. It also suggests that while the Chinese state is facing a pressing issue of supporting an increasing aging population and the Chinese family is coping with the burden of elder care, the insurance industry is playing an increasing role in elder care in China.

Trends in average days' supply of opioid medications in Medicaid and commercial insurance

OBJECTIVES

To calculate trends in adult average days' supply for six commonly prescribed opioids: hydrocodone, hydromorphone, morphine, oxycodone, oxymorphone, and tapentadol to assess whether physicians changed prescribing practices at the time of the intensifying epidemic.

METHODS

We used 2005-2015 Truven Health MarketScan Commercial Claims and Encounters data to measure trends in opioid average days' supply among commercially insured individuals and 2005-2014 MarketScan Multi-State Medicaid data to measure trends in opioid average days' supply among Medicaid beneficiaries.

RESULTS

For Medicaid, we found an increase in days' supply for all drugs except morphine. The largest percentage increase was for oxycodone, which increased 4.5days (37%). Opioid days' supply for individuals with commercial insurance exhibited similar but steeper trends. The largest increase was also for oxycodone, which increased 6days (56%). Between 2013 and 2015, when the opioid epidemic had begun to be widely publicized, there was no decline in the median days supplied for any of the opioids.

CONCLUSIONS

Our results find that days' supply of opioids are increasing despite public health campaigns and media attention on the risks of opioid prescribing. More effective interventions to curb opioid prescribing are needed to reverse these trends.