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Matthews S, Qureshi N, Levin JS, Eberhart NK, Breslau J, McBain RK. Financial Interventions to Improve Screening in Primary Care: A Systematic Review. Am J Prev Med 2024; 67:134-146. [PMID: 38484900 DOI: 10.1016/j.amepre.2024.03.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/18/2023] [Revised: 03/06/2024] [Accepted: 03/06/2024] [Indexed: 06/23/2024]
Abstract
INTRODUCTION Although health screenings offer timely detection of health conditions and enable early intervention, adoption is often poor. How might financial interventions create the necessary incentives and resources to improve screening in primary care settings? This systematic review aimed to answer this question. METHODS Peer-reviewed studies published between 2000 and 2023 were identified and categorized by the level of intervention (practice or individual) and type of intervention, specifically alternative payment models (APMs), fee-for-service (FFS), capitation, and capital investments. Outcomes included frequency of screening, performance/quality of care (e.g., patient satisfaction, health outcomes), and workflow changes (e.g., visit length, staffing). RESULTS Of 51 included studies, a majority focused on practice-level interventions (n=32), used APMs (n=41) that involved payments for achieving key performance indicators (KPIs; n=31) and were of low or very low strength of evidence based on GRADE criteria (n=42). Studies often included screenings for cancer (n=32), diabetes care (n=18), and behavioral health (n=15). KPI payments to both practices and individual providers corresponded with increased screening rates, whereas capitation and provider-level FFS models yielded mixed results. A large majority of studies assessed changes in screening rates (n=48) with less focus on quality of care (n=11) or workflow changes (n=4). DISCUSSION Financial mechanisms can enhance screening rates with evidence strongest for KPI payments to both practices and individual providers. Future research should explore the relationship between financial interventions and quality of care, in terms of both clinical processes and patient outcomes, as well as the role of these interventions in shaping care delivery.
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Affiliation(s)
| | | | | | | | | | - Ryan K McBain
- Department of Medicine, Brigham & Women's Hospital, Boston, Massachusetts; RAND Corporation, Arlington, Virginia
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Holm J, Pagán JA, Silver D. The Impact of Medicaid Accountable Care Organizations on Health Care Utilization, Quality Measures, Health Outcomes and Costs from 2012 to 2023: A Scoping Review. Med Care Res Rev 2024:10775587241241984. [PMID: 38618890 DOI: 10.1177/10775587241241984] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/16/2024]
Abstract
Most of the evidence regarding the success of ACOs is from the Medicare program. This review evaluates the impacts of ACOs within the Medicaid population. We identified 32 relevant studies published between 2012 and 2023 which analyzed the association of Medicaid ACOs and health care utilization (n = 21), quality measures (n = 18), health outcomes (n = 10), and cost reduction (n = 3). The results of our review regarding the effectiveness of Medicaid ACOs are mixed. Significant improvements included increased primary care visits, reduced admissions, and reduced inpatient stays. Cost reductions were reported in a few studies, and savings were largely dependent on length of attribution and years elapsed after ACO implementation. Adopting the ACO model for the Medicaid population brings some different challenges from those with the Medicare population, which may limit its success, particularly given differences in state Medicaid programs.
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Reif S, Brolin M, Beyene TM, D’Agostino N, Stewart MT, Horgan CM. Payment and Financing for Substance Use Screening and Brief Intervention for Adolescents and Adults in Health, School, and Community Settings. J Adolesc Health 2022; 71:S73-S82. [PMID: 36122974 PMCID: PMC9945348 DOI: 10.1016/j.jadohealth.2022.04.012] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/26/2021] [Revised: 04/01/2022] [Accepted: 04/27/2022] [Indexed: 10/14/2022]
Abstract
Screening and brief intervention (SBI) is an evidence-based, cost-effective practice to address unhealthy substance use. With SBI services expanding beyond healthcare settings (e.g., schools, community organizations) and reaching younger populations, sustainability efforts must consider payment and financing. This narrative review incorporated rapid scoping review methods and a search of the gray literature to determine payment and financing approaches for SBI with adolescents and to describe related barriers and facilitators for its sustainability. We sought information relevant to adolescents and settings in which they receive SBI, but also reviewed sources with an adult focus. Few peer-reviewed articles met inclusion criteria, and those mostly highlighted healthcare settings. School-based settings were better described in the gray literature; little was found about community settings. SBI is mostly paid through grant funding and public and commercial insurance; school-based settings use a range of approaches including grants, public insurance, and other public funding. We call upon researchers and providers to describe the payment and financing of SBI, to inform how the uptake of SBI may be practicable and sustainable. The increasing activation and use of insurance billing codes, and the expansion of SBI beyond healthcare, is encouraging to address unhealthy substance use by adolescents.
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Affiliation(s)
- Sharon Reif
- Institute for Behavioral Health, Heller School for Social Policy and Management, Brandeis University, Waltham, Massachusetts.
| | - Mary Brolin
- Institute for Behavioral Health, Heller School for Social Policy and Management, Brandeis University, 415 South Street, Waltham, MA, 02453, USA
| | - Tiginesh M. Beyene
- Institute for Behavioral Health, Heller School for Social Policy and Management, Brandeis University, 415 South Street, Waltham, MA, 02453, USA
| | - Nicole D’Agostino
- Institute for Behavioral Health, Heller School for Social Policy and Management, Brandeis University, 415 South Street, Waltham, MA, 02453, USA
| | - Maureen T. Stewart
- Institute for Behavioral Health, Heller School for Social Policy and Management, Brandeis University, 415 South Street, Waltham, MA, 02453, USA
| | - Constance M. Horgan
- Institute for Behavioral Health, Heller School for Social Policy and Management, Brandeis University, 415 South Street, Waltham, MA, 02453, USA
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Strategies to promote the implementation of Screening, Brief Intervention, and Referral to Treatment (SBIRT) in healthcare settings: a scoping review. SUBSTANCE ABUSE TREATMENT PREVENTION AND POLICY 2021; 16:42. [PMID: 33975614 PMCID: PMC8111985 DOI: 10.1186/s13011-021-00380-z] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Accepted: 04/29/2021] [Indexed: 12/12/2022]
Abstract
Background Screening, brief intervention, and referral to treatment (SBIRT), is an approach for the prevention and treatment of substance use disorders, but is often underutilized in healthcare settings. Although the implementation of SBIRT is challenging, the use of multi-faceted and higher intensity strategies are more likely to result in the successful incorporation of SBIRT into practice in primary care settings. SBIRT may be used in different healthcare settings, and the context for implementation and types of strategies used to support implementation may vary by setting. The purpose of this scoping review is to provide an overview regarding the use of strategies to support implementation of SBIRT in all healthcare settings and describe the associated outcomes. Methods A scoping review was conducted using CINAHL Complete, HealthBusiness FullTEXT, PsycINFO, PubMed, and Embase to search for articles published in English prior to September 2019. The search returned 462 citations, with 18 articles included in the review. Two independent reviewers extracted data from each article regarding the theory, design, timeline, location, setting, patient population, substance type, provider, sample size and type, implementation strategies, and implementation outcomes. The reviewers entered all extracted data entered into a table and then summarized the results. Results Most of the studies were conducted in the United States in primary care or emergency department settings, and the majority of studies focused on SBIRT to address alcohol use in adults. The most commonly used strategies to support implementation included training and educating stakeholders or developing stakeholder interrelationships. In contrast, only a few studies engaged patients or consumers in the implementation process. Efforts to support implementation often resulted in an increase in screening, but the evidence regarding the brief intervention is less clear, and most studies did not assess the reach or adoption of the referral to treatment. Discussion In addition to summarizing the strategies used to increase reach and adoption of SBIRT in healthcare settings, this scoping review identified multiple gaps in the literature. Two major gaps include implementation of SBIRT in acute care settings and the application of implementation theories to inform healthcare efforts to enable use of SBIRT.
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John WS, Zhu H, Greenblatt LH, Wu LT. Recent and active problematic substance use among primary care patients: Results from the alcohol, smoking, and substance involvement screening test in a multisite study. Subst Abus 2021; 42:487-492. [PMID: 33797348 PMCID: PMC9822781 DOI: 10.1080/08897077.2021.1901176] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
Abstract
Background: Primary care settings provide salient opportunities for identifying patients with problematic substance use and addressing unmet treatment need. The aim of this study was to examine the extent and correlates of problematic substance use by substance-specific risk categories among primary care patients to inform screening/intervention efforts. Methods: Data were analyzed from 2000 adult primary care patients aged ≥18 years (56% female) across 5 clinics in the eastern U.S. Participants completed the Alcohol, Smoking and Substance Involvement Screening Test (ASSIST). Prevalence and ASSIST-defined risk-level of tobacco use, alcohol use, and nonmedical/illicit drug use was examined. Multinomial logistic regression models analyzed the demographic correlates of substance use risk-levels. Results: Among the total sample, the prevalence of any past 3-month use was 53.9% for alcohol, 42.0% for tobacco, 24.2% for any illicit/Rx drug, and 5.3% for opioids; the prevalence of ASSIST-defined moderate/high-risk use was 45.1% for tobacco, 29.0% for any illicit/Rx drug, 14.2% for alcohol, and 9.1% for opioids. Differences in the extent and risk-levels of substance use by sex, race/ethnicity, and age group were observed. Adjusted logistic regression showed that male sex, white race, not being married, and having less education were associated with increased odds of moderate/high-risk use scores for each substance category; older ages (versus ages 18-25 years) were associated with increased odds of moderate/high-risk opioid use. Conclusions: Intervention need for problematic substance use was prevalent in this sample. Providers should maintain awareness and screen for problematic substance use more consistently in identified high risk populations.
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Affiliation(s)
- William S. John
- Department of Psychiatry and Behavioral Sciences, Duke University Medical Center, Durham, NC, USA
| | - He Zhu
- Department of Psychiatry and Behavioral Sciences, Duke University Medical Center, Durham, NC, USA
| | - Lawrence H. Greenblatt
- Division of General Internal Medicine, Department of Medicine, Duke University Medical Center, Durham, NC, USA
| | - Li-Tzy Wu
- Department of Psychiatry and Behavioral Sciences, Duke University Medical Center, Durham, NC, USA
- Division of General Internal Medicine, Department of Medicine, Duke University Medical Center, Durham, NC, USA
- Center for Child and Family Policy, Sanford School of Public Policy, Duke University, Durham, NC, USA
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Carlo AD, Benson NM, Chu F, Busch AB. Association of Alternative Payment and Delivery Models With Outcomes for Mental Health and Substance Use Disorders: A Systematic Review. JAMA Netw Open 2020; 3:e207401. [PMID: 32701157 PMCID: PMC7378751 DOI: 10.1001/jamanetworkopen.2020.7401] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
IMPORTANCE Health care spending in the United States continues to grow. Mental health and substance use disorders (MH/SUDs) are prevalent and associated with worse health outcomes and higher health care spending; alternative payment and delivery models (APMs) have the potential to facilitate higher quality, integrated, and more cost-effective MH/SUD care. OBJECTIVE To systematically review and summarize the published literature on populations and MH/SUD conditions examined by APM evaluations and the associations of APMs with MH/SUD outcomes. EVIDENCE REVIEW A literature search of MEDLINE, PsychInfo, Scopus, and Business Source was conducted from January 1, 1997, to May 17, 2019, for publications examining APMs for MH/SUD services, assessing at least 1 MH/SUD outcome, and having a comparison group. A total of 27 articles met these criteria, and each was classified according to the Health Care Payment Learning and Action Network's APM framework. Strength of evidence was graded using a modified Oxford Centre for Evidence-Based Medicine framework. FINDINGS The 27 included articles evaluated 17 APM implementations that spanned 3 Health Care Payment Learning and Action Network categories and 6 subcategories, with no single category predominating the literature. APMs varied with regard to their assessed outcomes, funding sources, target populations, and diagnostic focuses. The APMs were primarily evaluated on their associations with process-of-care measures (15 [88.2%]), followed by utilization (11 [64.7%]), spending (9 [52.9%]), and clinical outcomes (5 [29.4%]). Medicaid and publicly funded SUD programs were most common, with each representing 7 APMs (41.2%). Most APMs focused on adults (11 [64.7%]), while fewer (2 [11.8%]) targeted children or adolescents. More than half of the APMs (9 [52.9%]) targeted populations with SUD, while 4 (23.5%) targeted MH populations, and the rest targeted MH/SUD broadly defined. APMs were most commonly associated with improvements in MH/SUD process-of-care outcomes (12 of 15 [80.0%]), although they were also associated with lower spending (4 of 8 [50.0%]) and utilization (5 of 11 [45.5%]) outcomes, suggesting gains in value from APMs. However, clinical outcomes were rarely measured (5 APMs [29.4%]). A total of 8 APMs (47.1%) assessed for gaming (ie, falsification of outcomes because of APM incentives) and adverse selection, with 1 (12.5%) showing evidence of gaming and 3 (37.5%) showing evidence of adverse selection. Other than those assessing accountable care organizations, few studies included qualitative evaluations. CONCLUSIONS AND RELEVANCE In this study, APMs were associated with improvements in process-of-care outcomes, reductions in MH/SUD utilization, and decreases in spending. However, these findings cannot fully substitute for assessments of clinical outcomes, which have rarely been evaluated in this context. Additionally, this systematic review identified some noteworthy evidence for gaming and adverse selection, although these outcomes have not always been duly measured or analyzed. Future research is needed to better understand the varied qualitative experiences across APMs, their successful components, and their associations with clinical outcomes among diverse populations and settings.
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Affiliation(s)
- Andrew D. Carlo
- Department of Psychiatry and Behavioral Sciences, University of Washington School of Medicine, Seattle
| | | | - Frances Chu
- University of Washington School of Nursing, Seattle
| | - Alisa B. Busch
- Department of Health Care Policy, McLean Hospital, Harvard Medical School, Boston, Massachusetts
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McCarty D, Gu Y, Renfro S, Baker R, Lind BK, McConnell KJ. Access to treatment for alcohol use disorders following Oregon's health care reforms and Medicaid expansion. J Subst Abuse Treat 2018; 94:24-28. [PMID: 30243413 PMCID: PMC6205746 DOI: 10.1016/j.jsat.2018.08.002] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2018] [Revised: 07/03/2018] [Accepted: 08/06/2018] [Indexed: 12/21/2022]
Abstract
The study examines impacts of delivery system reforms and Medicaid expansion on treatment for alcohol use disorders within the Oregon Health Plan (Medicaid). Diagnoses, services and pharmacy claims related to alcohol use disorders were extracted from Medicaid encounter data. Logistic regression and interrupted time series analyses assessed the percent with alcohol use disorder entering care and the percent receiving pharmacotherapy before (January 2010-June 2012) and after (January 2013-June 2015) the initiation of Oregon's Coordinated Care Organization (CCO) model (July 2012-December 2012). Analyses also examined changes in access following Medicaid expansion (January 2014). Treatment entry rates increased from 35% in 2010 to 41% in 2015 following the introduction of CCOs and Medicaid expansion. The number of Medicaid enrollees with a diagnosed alcohol use disorder increased about 150% from 10,360 (2013) to 25,454 (2014) following Medicaid expansion. Individuals with an alcohol use disorder who were prescribed a medication to support recovery increased from 2.3% (2010) to 3.8% (2015). In Oregon, Medicaid expansion and health care reforms enhanced access and improved treatment initiation for alcohol use disorders.
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Affiliation(s)
- Dennis McCarty
- OHSU - PSU School of Public Health, Oregon Health & Science University, Portland, OR, United States of America; Department of Psychiatry, Oregon Health & Science University, Portland, OR, United States of America.
| | - Yifan Gu
- Center for Health Systems Effectiveness, Oregon Health & Science University, Portland, OR, United States of America
| | - Stephanie Renfro
- Center for Health Systems Effectiveness, Oregon Health & Science University, Portland, OR, United States of America
| | - Robin Baker
- OHSU - PSU School of Public Health, Oregon Health & Science University, Portland, OR, United States of America
| | - Bonnie K Lind
- Center for Health Systems Effectiveness, Oregon Health & Science University, Portland, OR, United States of America; Department of Emergency Medicine, Oregon Health & Science University, Portland, OR, United States of America
| | - K John McConnell
- OHSU - PSU School of Public Health, Oregon Health & Science University, Portland, OR, United States of America; Center for Health Systems Effectiveness, Oregon Health & Science University, Portland, OR, United States of America; Department of Emergency Medicine, Oregon Health & Science University, Portland, OR, United States of America
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McNeely J, Kumar PC, Rieckmann T, Sedlander E, Farkas S, Chollak C, Kannry JL, Vega A, Waite EA, Peccoralo LA, Rosenthal RN, McCarty D, Rotrosen J. Barriers and facilitators affecting the implementation of substance use screening in primary care clinics: a qualitative study of patients, providers, and staff. Addict Sci Clin Pract 2018; 13:8. [PMID: 29628018 PMCID: PMC5890352 DOI: 10.1186/s13722-018-0110-8] [Citation(s) in RCA: 145] [Impact Index Per Article: 24.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2017] [Accepted: 01/30/2018] [Indexed: 11/10/2022] Open
Abstract
Background
Alcohol and drug use are leading causes of morbidity and mortality that frequently go unidentified in medical settings. As part of a multi-phase study to implement electronic health record-integrated substance use screening in primary care clinics, we interviewed key clinical stakeholders to identify current substance use screening practices, barriers to screening, and recommendations for its implementation. Methods Focus groups and individual interviews were conducted with 67 stakeholders, including patients, primary care providers (faculty and resident physicians), nurses, and medical assistants, in two urban academic health systems. Themes were identified using an inductive approach, revised through an iterative process, and mapped to the Knowledge to Action (KTA) framework, which guides the implementation of new clinical practices (Graham et al. in J Contin Educ Health Prof 26(1):13–24, 2006). Results Factors affecting implementation based on KTA elements were identified from participant narratives. Identifying the problem: Participants consistently agreed that having knowledge of a patient’s substance use is important because of its impacts on health and medical care, that substance use is not properly identified in medical settings currently, and that universal screening is the best approach. Assessing barriers: Patients expressed concerns about consequences of disclosing substance use, confidentiality, and the individual’s own reluctance to acknowledge a substance use problem. Barriers identified by providers included individual-level factors such as lack of clinical knowledge and training, as well as systems-level factors including time pressure, resources, lack of space, and difficulty accessing addiction treatment. Adapting to the local context: Most patients and providers stated that the primary care provider should play a key role in substance use screening and interventions. Opinions diverged regarding the optimal approach to delivering screening, although most preferred a patient self-administered approach. Many providers reported that taking effective action once unhealthy substance use is identified is crucial.
Conclusions Participants expressed support for substance use screening as a valuable part of medical care, and identified individual-level as well as systems-level barriers to its implementation. These findings suggest that screening programs should clearly communicate the goals of screening to patients and proactively counteract stigma, address staff concerns regarding time and workflow, and provide education as well as treatment resources to primary care providers. Electronic supplementary material The online version of this article (10.1186/s13722-018-0110-8) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Jennifer McNeely
- Department of Population Health, New York University School of Medicine, 550 First Avenue, VZ30 6th Floor, New York, NY, 10016, USA. .,Division of General Internal Medicine, Department of Medicine, New York University School of Medicine, 550 First Avenue, New York, NY, 10016, USA.
| | - Pritika C Kumar
- Department of Population Health, New York University School of Medicine, 550 First Avenue, VZ30 6th Floor, New York, NY, 10016, USA
| | - Traci Rieckmann
- Greenfield Health and Department of Psychiatry, Oregon Health and Science University, 9450 SW Barnes Suite 100, Portland, OR, 97225, USA
| | - Erica Sedlander
- Department of Population Health, New York University School of Medicine, 550 First Avenue, VZ30 6th Floor, New York, NY, 10016, USA
| | - Sarah Farkas
- Department of Psychiatry, New York University School of Medicine, One Park Avenue, 8th Floor, New York, NY, 10016, USA
| | - Christine Chollak
- Department of Population Health, New York University School of Medicine, 550 First Avenue, VZ30 6th Floor, New York, NY, 10016, USA
| | - Joseph L Kannry
- Division of General Internal Medicine, Department of Medicine, Icahn School of Medicine at Mt. Sinai, One Gustave L. Levy Place, New York, NY, 10029, USA
| | - Aida Vega
- Division of General Internal Medicine, Department of Medicine, Icahn School of Medicine at Mt. Sinai, One Gustave L. Levy Place, New York, NY, 10029, USA
| | - Eva A Waite
- Division of General Internal Medicine, Department of Medicine, Icahn School of Medicine at Mt. Sinai, One Gustave L. Levy Place, New York, NY, 10029, USA
| | - Lauren A Peccoralo
- Division of General Internal Medicine, Department of Medicine, Icahn School of Medicine at Mt. Sinai, One Gustave L. Levy Place, New York, NY, 10029, USA
| | - Richard N Rosenthal
- Department of Psychiatry, Icahn School of Medicine at Mt. Sinai, 1090 Amsterdam Avenue, New York, NY, 10025, USA
| | - Dennis McCarty
- OHSU-PSU School of Public Health, Oregon Health and Science University, 3181 SW Sam Jackson Park Road, Portland, OR, 97239, USA
| | - John Rotrosen
- Department of Psychiatry, New York University School of Medicine, One Park Avenue, 8th Floor, New York, NY, 10016, USA
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