Licensure Policies May Help States Ensure Access To Opioid Use Disorder Medication In Specialty Addiction Treatment

Despite the devastating toll of the overdose crisis in the United States, many addiction treatment programs do not offer medications for opioid use disorder (MOUD). Several states have incorporated MOUD requirements into their standards for treatment program licensure. This study examined policy officials' and treatment providers' perspectives on the implementation of these policies. During 2020-22, we conducted thirty-one semistructured interviews with forty policy officials and treatment providers in nine states identified through a legal analysis. Of these states, three states required treatment organizations to offer MOUD, and two prohibited organizations from denying admission to people receiving MOUD. Qualitative findings revealed that licensure policies were part of a broader effort to transition the specialty treatment system to a model of care more consistent with medical evidence; states perceived tension between raising quality standards and maintaining adequate treatment capacity; aligning other state policies with MOUD access goals facilitated implementation of the licensure requirement; and measuring compliance was challenging. Licensure may offer states an opportunity to take a more active role in ensuring access to effective treatment.

Deductible imputation in administrative medical claims datasets

OBJECTIVE

To validate imputation methods used to infer plan-level deductibles and determine which enrollees are in high-deductible health plans (HDHPs) in administrative claims datasets.

DATA SOURCES AND STUDY SETTING

2017 medical and pharmaceutical claims from OptumLabs Data Warehouse for US individuals <65 continuously enrolled in an employer-sponsored plan. Data include enrollee and plan characteristics, deductible spending, plan spending, and actual plan-level deductibles.

STUDY DESIGN

We impute plan deductibles using four methods: (1) parametric prediction using individual-level spending; (2) parametric prediction with imputation and plan characteristics; (3) highest plan-specific mode of individual annual deductible spending; and (4) deductible spending at the 80th percentile among individuals meeting their deductible. We compare deductibles' levels and categories for imputed versus actual deductibles.

DATA COLLECTION/EXTRACTION METHODS

Not applicable.

PRINCIPAL FINDINGS

All methods had a positive predictive value (PPV) for determining high- versus low-deductible plans of ≥87%; negative predictive values (NPV) were lower. The method imputing plan-specific deductible spending modes was most accurate and least computationally intensive (PPV: 95%; NPV: 91%). This method also best correlated with actual deductible levels; 69% of imputed deductibles were within $250 of the true deductible.

CONCLUSIONS

In the absence of plan structure data, imputing plan-specific modes of individual annual deductible spending best correlates with true deductibles and best predicts enrollees in HDHPs.

Changes in Healthcare Spending Attributable to High Deductible Health Plan Offer Among Enrollees with Comorbid Substance Use Disorder and Cardiovascular Disease

BACKGROUND

The rise in prevalence of high deductible health plans (HDHPs) in the United States may raise concerns for high-need, high-utilization populations such as those with comorbid chronic conditions. In this study, we examine changes in total and out-of-pocket (OOP) spending attributable to HDHPs for enrollees with comorbid substance use disorder (SUD) and cardiovascular disease (CVD).

METHODS

We used de-identified administrative claims data from 2007 to 2017. SUD and CVD were defined using algorithms of ICD 9 and 10 codes and HEDIS guidelines. The main outcome measures of interest were spending measure for all non-SUD/CVD-related services, SUD-specific services, and CVD-specific services, for all services and medications specifically. We assessed both total and OOP spending. We used an intent-to-treat two-part model approach to model spending and computed the marginal effect of HDHP offer as both the dollar change and percent change in spending attributable to HDHP offer.

RESULTS

Our sample included 33,684 enrollee-years and was predominantly white and male with a mean age of 53 years. The sample had high demonstrated substantial healthcare utilization with 94% using any non-SUD/CVD services, and 84% and 78% using SUD and CVD services, respectively. HDHP offer was associated with a 17.0% (95% CI = [0.07, 0.27] increase in OOP spending for all non-SUD/CVD services, a 21.1% (95% CI = [0.11, 0.31]) increase in OOP spending for all SUD-specific services, and a 13.1% (95% CI = [0.04, 0.23]) increase in OOP spending for all CVD-specific services. HDHP offer was also associated with a significant increase in OOP spending on non-SUD/CVD-specific medications and SUD-specific medications, but not CVD-specific medications.

CONCLUSIONS

This study suggests that while HDHPs do not change overall levels of annual spending among enrollees with comorbid CVD and SUD, they may increase the financial burden of healthcare services by raising OOP costs, which could negatively impact this high-need and high-utilization population.

Navigating addiction treatment during COVID-19: policy insights from state health leaders

To mitigate pandemic-related disruptions to addiction treatment, US federal and state governments made significant changes to policies regulating treatment delivery. State health agencies played a key role in implementing these policies, giving agency leaders a distinct vantage point on the feasibility and implications of post-pandemic policy sustainment. We interviewed 46 state health agency and other leaders responsible for implementing COVID-19 addiction treatment policies across 8 states with the highest COVID-19 death rate in their census region. Semi-structured interviews were conducted from April through October 2022. Transcripts were analyzed using summative content analysis to characterize policies that interviewees perceived would, if sustained, benefit addiction treatment delivery long-term. State policies were then characterized through legal database queries, internet searches, and analysis of existing policy databases. State leaders viewed multiple pandemic-era policies as useful for expanding addiction treatment access post-pandemic, including relaxing restrictions for telehealth, particularly for buprenorphine induction and audio-only treatment; take-home methadone allowances; mobile methadone clinics; and out-of-state licensing flexibilities. All states adopted at least 1 of these policies during the pandemic. Future research should evaluate these policies outside of the acute COVID-19 pandemic context.

Anxiety and Depression Symptoms After the Dobbs Abortion Decision

Importance

In 2022, the US Supreme Court abolished the federal right to abortion in the Dobbs v Jackson Women's Health Organization decision. In 13 states, abortions were immediately banned via previously passed legislation, known as trigger laws.

Objective

To estimate changes in anxiety and depression symptoms following the Dobbs decision among people residing in states with trigger laws compared with those without them.

Design, Setting, and Participants

Using the nationally representative repeated cross-sectional Household Pulse Survey (December 2021-January 2023), difference-in-differences models were estimated to examine the change in symptoms of depression and anxiety after Dobbs (either the June 24, 2022, Dobbs decision, or its May 2, 2022, leaked draft benchmarked to the baseline period, prior to May 2, 2022) by comparing the 13 trigger states with the 37 nontrigger states. Models were estimated for the full population (N = 718 753), and separately for 153 108 females and 102 581 males aged 18 through 45 years.

Exposure

Residing in states with trigger laws following the Dobbs decision or its leaked draft.

Main Outcomes and Measures

Anxiety and depression symptoms were measured via the Patient Health Questionnaire-4 ([PHQ-4]; range, 0-12; scores of more than 5 indicate elevated depression or anxiety symptoms; minimal important difference unknown).

Results

The survey response rate was 6.04% overall, and 87% of respondents completed the PHQ-4. The population-weighted mean age was 48 years (SD, 17 years), and 51% were female. In trigger states, the mean PHQ-4 scores in the baseline period and after the Dobbs decision were 3.51 (95% CI, 3.44 to 3.59) and 3.81 (95% CI, 3.75 to 3.87), respectively, and in nontrigger states were 3.31 (95% CI, 3.27 to 3.34) and 3.49 (95% CI, 3.45 to 3.53), respectively. There was a significantly greater increase in the mean PHQ-4 score by 0.11 (95% CI, 0.06 to 0.16; P < .001) in trigger states vs nontrigger states. From baseline to after the draft was leaked, the change in PHQ-4 was not significantly different for those in trigger states vs nontrigger states (difference-in-differences estimate, 0.09; 95% CI, -0.03 to 0.21; P = .15). From baseline to after the Dobbs opinion, there was a significantly greater increase in mean PHQ-4 scores for those in trigger states vs nontrigger states among females aged 18 through 45 years (difference-in-differences estimate, 0.23; 95% CI, 0.08 to 0.37; P = .002). Among males aged 18 through 45 years, the difference-in-differences estimate was not statistically significant (0.14; 95% CI, -0.08 to 0.36; P = .23). Differences in estimates for males and females aged 18 through 45 were statistically significant (P = .02).

Conclusions and Relevance

In this study of US survey data from December 2021 to January 2023, residence in states with abortion trigger laws compared with residence in states without such laws was associated with a small but significantly greater increase in anxiety and depression symptoms after the Dobbs decision.

Job Flows Into and Out of Health Care Before and After the COVID-19 Pandemic

Importance

Anecdotal evidence suggests that health care employers have faced increased difficulty recruiting and retaining staff in the wake of the COVID-19 pandemic. Empirical research is needed to understand the magnitude and persistence of these changes, and whether they have disproportionate implications for certain types of workers or regions of the country.

Objective

To quantify the number of workers exiting from and entering into the health care workforce before and after the pandemic and to examine variations over time and across states and worker demographics.

Design, Setting, and Participants

This cohort study used US Census Bureau state unemployment insurance data on job-to-job flows in the continental US to construct state-level quarterly exit and entry rates for the health care industry from January 2018 through December 2021 (Arkansas, Mississippi, and Tennessee were omitted due to missing data). An event study design was used to compute quarterly mean adjusted rates of job exit from and entry into the health care sector as defined by the North American Industry Classification System. Data were examined from January to June 2023.

Exposure

The COVID-19 pandemic.

Main Outcomes and Measures

The main outcomes were the mean adjusted health care worker exit and entry rates in each quarter by state and by worker demographics (age, gender, race and ethnicity, and education level).

Results

In quarter 1 of 2020, there were approximately 18.8 million people (14.6 million females [77.6%]) working in the health care sector in our sample. The exit rate for health care workers increased at the onset of the pandemic, from a baseline quarterly mean of 5.9 percentage points in 2018 to 8.0 (95% CI, 7.7-8.3) percentage points in quarter 1 of 2020. Exit rates remained higher than baseline levels through quarter 4 of 2021, when the health care exit rate was 7.7 (95% CI, 7.4-7.9) percentage points higher than the 2018 baseline. In quarter 1 of 2020, the increase in health care worker exit rates was dominated by an increase in workers exiting to nonemployment (78% increase compared with baseline); in contrast, by quarter 4 of 2021, the exit rate was dominated by workers exiting to employment in non-health care sectors (38% increase compared with baseline). Entry rates into health care also increased in the postpandemic period, from 6.2 percentage points at baseline to 7.7 percentage points (95% CI, 7.4-7.9 percentage points) in the last quarter of 2021, suggesting increased turnover of health care staff. Compared with prepandemic job flows, the share of workers exiting health care after the pandemic who were female was disproportionately larger, and the shares of workers entering health care who were female or Black was disproportionately smaller.

Conclusions and Relevance

Results of this cohort study suggest a substantial and persistent increase in health care workforce turnover after the pandemic, which may have long-lasting implications for workers' willingness to remain in health care jobs. Policymakers and health care organizations may need to act to prevent further losses of experienced staff.

Trends in Opioid Use Disorder Outpatient Treatment and Telehealth Utilization Before and During the COVID-19 Pandemic

OBJECTIVE

The authors examined trends in opioid use disorder treatment and in-person and telehealth modalities before and after COVID-19 pandemic onset among patients who had received treatment prepandemic.

METHODS

The sample included 13,113 adults with commercial insurance or Medicare Advantage and receiving opioid use disorder treatment between March 2018 and February 2019. Trends in opioid use disorder outpatient treatment, treatment with medications for opioid use disorder (MOUD), and in-person and telehealth modalities were examined 1 year before pandemic onset and 2 years after (March 2019-February 2022).

RESULTS

From March 2019 to February 2022, the proportion of patients with opioid use disorder outpatient and MOUD visits declined by 2.8 and 0.3 percentage points, respectively. Prepandemic, 98.6% of outpatient visits were in person; after pandemic onset, at least 34.9% of patients received outpatient care via telehealth.

CONCLUSIONS

Disruptions in opioid use disorder outpatient and MOUD treatments were marginal during the pandemic, possibly because of increased telehealth utilization.

Choice of high-deductible health plans among enrollees with a substance use disorder

INTRODUCTION

High-deductible health plans (HDHPs) expose enrollees to increased out-of-pocket costs for their medical care, which can exacerbate the undertreatment of substance use disorders (SUDs). However, the factors that influence whether an enrollee with SUD chooses an HDHP are not well understood. In this study, we examine the factors associated with an individual with an SUD's decision to enroll in an HDHP.

METHODS

Using de-identified administrative commercial claims and enrollment data from OptumLabs (2007-2017), we identified individuals at employers offering at least one HDHP and one non-HDHP plan. We modeled whether an enrollee chose an HDHP using linear regression on plan and enrollee demographic characteristics. Key plan characteristics included whether a plan had a health savings account (HSA) or a health reimbursement arrangement (HRA). Key demographic variables included age, race/ethnicity, census block income range, census block highest educational attainment, and sex. We separately investigate new enrollment decisions (i.e., not previously enrolled in an HDHP) and re-enrollment decisions, as well as decisions among single enrollees and families of differing sizes. The study also adjusted models for additional plan characteristics, employer and year fixed effects, and census division. Robust standard errors were clustered at the employer level.

RESULTS

The sample comprised 30,832 plans and 318,334 enrollees. Among enrollees with new enrollment decisions, 24.6 % chose an HDHP; 93.8 % of HDHP enrollees chose to re-enroll in an HDHP. The study found the presence of a plan HRA to be associated with a higher probability of new and re-enrollment in an HDHP. We found that older enrollees with SUD were less likely to newly enroll in an HDHP, while enrollees who were non-White, living in lower-income census blocks, and living in lower educational attainment census blocks were more likely to newly enroll in an HDHP. Higher levels of health care utilization in the prior year were associated with a lower probability of newly enrolling in an HDHP but associated with a higher probability of re-enrolling.

CONCLUSION

Given the emerging evidence that HDHPs may discourage SUD treatment, greater HDHP enrollment could exacerbate health disparities.

Impact of High Deductible Health Plans on U.S. Adults With Chronic Pain

INTRODUCTION

Chronic pain affects an estimated 20% of U.S. adults. Because high-deductible health plans have captured a growing share of the commercial insurance market, it is unknown how high-deductible health plans impact care for chronic pain.

METHODS

Using 2007-2017 claims data from a large national commercial insurer, statistical analyses conducted in 2022-2023 estimated changes in enrollee outcomes before and after their firm began offering a high-deductible health plan compared with changes in outcomes in a comparison group of enrollees at firms never offering a high-deductible health plan. The sample included 757,530 commercially insured adults aged 18-64 years with headache, low back pain, arthritis, neuropathic pain, or fibromyalgia. Outcomes, measured at the enrollee year level, included the probability of receiving any chronic pain treatment, nonpharmacologic pain treatment, and opioid and nonopioid prescriptions; the number of nonpharmacologic pain treatment days; number and days' supply of opioid and nonopioid prescriptions; and total annual spending and out-of-pocket spending.

RESULTS

High-deductible health plan offer was associated with a 1.2 percentage point reduction (95% CI= -1.8, -0.5) in the probability of any chronic pain treatment and an $11 increase (95% CI=$6, $15) in annual out-of-pocket spending on chronic pain treatments among those with any use, representing a 16% increase in average annual out-of-pocket spending over the pre-high deductible health plan offer annual average. Results were driven by changes in nonpharmacologic treatment use.

CONCLUSIONS

By reducing the use of nonpharmacologic chronic pain treatments and marginally increasing out-of-pocket costs among those using these services, high-deductible health plans may discourage more holistic, integrated approaches to caring for patients with chronic pain conditions.

High-Deductible Health Plans' Impact on Mental Health and Substance Use Disorder Treatments-Balancing Cost and Care

This Viewpoint examines the effects of high-deductible health plans (HDHPs) on individuals with mental health and substance use disorders, which is crucial for informing policy and regulatory decisions.

Do High-Deductible Health Plans Incentivize Changing the Timing of Substance Use Disorder Treatment?

A high-deductible health plan (HDHP) may incentivize enrollees to limit health care use at the beginning of a plan year, when they are responsible for 100% of costs, or to increase the use of care at the end of the year, when enrollees may have less cost exposure. We investigated both the impact of the deductible reset that occurs at the beginning of a plan year and the option to enroll in an HDHP on the use of substance use disorder (SUD) treatment services over the course of a health plan year. We found decreases in SUD treatment use following the increase in cost exposure related to a deductible reset. There was no variation in this behavior between HDHP offer enrollees and comparison enrollees who were not offered an HDHP. These findings reinforce that cost-sharing poses a barrier to SUD care and continuity of care, which can increase the risk of adverse clinical outcomes.

High-deductible Health Plans and Nonfatal Opioid Overdose

OBJECTIVES

Opioid-related overdose is a public health emergency in the United States. Meanwhile, high-deductible health plans (HDHPs) have become more prevalent in the United States over the last 2 decades, raising concern about their potential for discouraging high-need populations, like those with opioid use disorder (OUD), from engaging in care that may mitigate the probability of overdose. This study assesses the impact of an employer offering an HDHP on nonfatal opioid overdose among commercially insured individuals with OUD in the United States.

RESEARCH DESIGN

We used deidentified insurance claims data from 2007 to 2017 with 97,788 person-years. We used an intent-to-treat, difference-in-differences regression framework to estimate the change in the probability of a nonfatal opioid overdose among enrollees with OUD whose employers began offering an HDHP insurance option during the study period compared with the change among those whose employer never offered an HDHP. We also used an event-study model to account for dynamic time-varying treatment effects.

RESULTS

Across both comparison and treatment groups, 2% of the sample experienced a nonfatal opioid overdose during the study period. Our primary model and robustness checks revealed no impact of HDHP offer on the probability of a nonfatal overdose.

CONCLUSIONS

Our study suggests that HDHP offer was not associated with an observed increase in the probability of nonfatal opioid overdose among commercially insured person-years with OUD. However, given the strong evidence that medications for OUD (MOUD) can reduce the risk of overdose, research should explore which facets of insurance design may impact MOUD use.

Is exposure to pharmaceutical direct-to-consumer advertising for heart disease and diabetes associated with physical activity and dietary behavior?

CONTEXT

Scholars have suggested that direct-to-consumer advertising (DTCA) of prescription drugs may discourage or encourage changes in lifestyle to improve health. The current paper informs this debate by examining associations between estimated exposure to DTCA for drugs focused on heart disease/cholesterol and diabetes and self-reported exercise and consumption of a variety of unhealthy foods (candy, sugary drinks, alcohol, and fast food).

METHODS

We estimated exposure to DTCA by combining data from Kantar Media Intelligence (Kantar) on televised pharmaceutical DTCA airings in the U.S. from January 2003 to August 2016 (n = 7,696,851 airings) with thirteen years of data from the Simmons National Consumer Survey (Simmons), a mailed survey on television viewing patterns. We estimated associations between exposure to advertising (both overall and for advertisements with specific content) and self-reported physical activity and dietary behavior using Simmons data from January 2004 to December 2016 (n = 288,483 respondents from n = 157,621 unique households in the U.S.). Our analysis controls for many potential confounders including respondent demographics, temporal trends, and program placement to account for purposeful ad targeting to higher-risk adults.

FINDINGS

Higher estimated exposure to DTCA for heart disease and diabetes drugs were not consistently associated with meaningful differences in the frequency of engaging in regular physical activity. Greater estimated exposure to DTCA for both diseases were, linked to small but consistently higher volume of consumption of candy, sugar-sweetened beverages, alcohol, and fast food. Specific DTCA message content about diet and exercise explained very little of the observed association between overall DTCA exposure volume and study outcomes.

CONCLUSIONS

Many Americans were regularly exposed to pharmaceutical DTCA for heart disease and diabetes from 2003 to 2016. Widespread exposure to such DTCA is associated with higher levels (though small in magnitude) of consuming alcohol, fast food, candy, and sugar-sweetened beverages.

Measurement Approaches to Estimating Methadone Continuity in Opioid Use Disorder Care

BACKGROUND

Long-term treatment with medications for opioid use disorder (OUD), including methadone, is lifesaving. There has been little examination of how to measure methadone continuity in claims data.

OBJECTIVES

To develop an approach for measuring methadone continuity in claims data, and compare estimates of methadone versus buprenorphine continuity.

RESEARCH DESIGN

Observational cohort study using de-identified commercial claims from OptumLabs Data Warehouse (January 1, 2017-June 30, 2021).

SUBJECTS

Individuals diagnosed with OUD, ≥1 methadone or buprenorphine claim and ≥180 days continuous enrollment (N=29,633).

MEASURES

OUD medication continuity: months with any use, days of continuous use, and proportion of days covered.

RESULTS

5.4% (N=1607) of the study cohort had any methadone use. Ninety-seven percent of methadone claims (N=160,537) were from procedure codes specifically used in opioid treatment programs. Place of service and primary diagnosis codes indicated that several methadone procedure codes were not used in outpatient OUD care. Methadone billing patterns indicated that estimating days-supply based solely on dates of service and/or procedure codes would yield inaccurate continuity results and that an approach incorporating the time between service dates was more appropriate. Among those using methadone, mean [s.d.] months with any use, days of continuous use, and proportion of days covered were 4.8 [1.8] months, 79.7 [73.4] days, and 0.64 [0.36]. For buprenorphine, the corresponding continuity estimates were 4.6 [1.9], 80.7 [70.0], and 0.73 [0.35].

CONCLUSIONS

Estimating methadone continuity in claims data requires a different approach than that for medications largely delivered by prescription fills, highlighting the importance of consistency and transparency in measuring methadone continuity across studies.

Factors Associated With Public Trust in Pharmaceutical Manufacturers

This cross-sectional study examines how key demographic and predisposing factors are associated with consumer trust in pharmaceutical manufacturers.

Association between non-profit hospital community benefit spending and health outcomes

OBJECTIVE

To determine if greater non-profit hospital spending for community benefits is associated with better health outcomes in the county where they are located.

DATA SOURCES AND STUDY SETTING

Community benefit data from IRS Form 990/Schedule H was linked to health outcome data from Area Health Resource Files, Map the Meal Gap, and Medicare claims from the Center for Medicare and Medicaid Services at the county level. Counties with at least one non-profit hospital in the United States from 2015 to 2019 (N = 5469 across the 5 years) were included.

STUDY DESIGN

We ran multiple regressions on community benefit expenditures linked with the number of health professionals, food insecurity, and adherence to diabetes and hypertension medication for each county.

DATA COLLECTION

The three outcomes were chosen based on prior studies of community benefit and a recent survey sent to 12 health care executives across four regions of the U.S. Data on community benefit expenditures and health outcomes were aggregated at the county level.

PRINCIPAL FINDINGS

Average hospital community benefit spending in 2019 was $63.6 million per county ($255 per capita). Multivariable regression results did not demonstrate significant associations of total community benefit spending with food insecurity or medication adherence for diabetes. Statistically significant associations with the number of health professionals per 1000 (coefficient, 12.10; SE, 0.32; p < 0.001) and medication adherence for hypertension (marginal effect, 0.27; SE, 0.09; p = 0.003) were identified, but both would require very large increases in community benefit spending to meaningfully improve outcomes.

CONCLUSIONS

Despite varying levels of non-profit hospital community benefit investment across counties, higher community benefit expenditures are not associated with an improvement in the selected health outcomes at the county level. Hospitals can use this information to reassess community benefit strategies, while federal, state, and local governments can use these findings to redefine the measures of community benefit they use to monitor and grant tax exemption.

High deductible health plans and spending among families with a substance use disorder

BACKGROUND

The United States faces an ongoing drug crisis, worsened by the undertreatment of substance use disorders (SUDs). Family enrollment in high deductible health plans (HDHPs) and the resulting increased cost exposure could exacerbate the undertreatment of SUD. This study characterized the distribution of health care spending within families where a member has a SUD and estimated the association between HDHPs and family health care spending.

METHODS

Using commercial claims and enrollment data from OptumLabs (2007-2017), we identified a treatment group of enrollees whose employers began offering an HDHP and comparison group whose employers never offered an HDHP. We used a difference-in-differences analysis that compared health care spending in families at firms that did vs. did not offer an HDHP before and after the HDHP offer. All models were adjusted for employer and year fixed effects, as well as family demographics, size, and chronic conditions.

RESULTS

Our sample was comprised of 317,353 family-years. Family members with a SUD, on average, contributed an outsized proportion of total family health care expenditures (56.9% in a family of three). Offering a family HDHP was associated with a 6.1% reduction (95% confidence interval [CI]: 9.7-2.6%) in the probability of families having any SUD-related expenditures. The HDHP offer was associated with a $1546 reduction in family total expenditures and a $1185 reduction for the individual with SUD (95% CI: -2272 to -821 and -1845 to -525, respectively).

CONCLUSIONS

The increased prevalence of family enrollment in HDHPs may further the existing issue of undertreatment of SUDs.

Employment in Office-Based and Intensive Behavioral Health Settings in the US, 2016-2021

This study uses employment census data to show trends in behavioral health employment during and after the COVID-19 pandemic.

The impact of HDHPs on service use and spending for substance use disorders

OBJECTIVES

Although high-deductible health plans (HDHPs) reduce health care spending, higher deductibles may lead to forgone care. Our goal was to determine the effects of HDHPs on the use of and spending on substance use disorder (SUD) services.

STUDY DESIGN

We used difference-in-differences models to compare service use and spending for treating SUD among enrollees who were newly offered an HDHP relative to enrollees offered only traditional plan options throughout the study period.

METHODS

We used deidentified commercial claims data from OptumLabs (2007-2017) to identify a sample of 28,717,236 person-years (2.2% with a diagnosed SUD). The main independent measure was an indicator for being offered an HDHP. The main dependent measures were the probability of (and spending associated with) using SUD services and specific treatment types.

RESULTS

Enrollees were 6.6% (P < .001) less likely to use SUD services after being offered an HDHP relative to the comparison group. Reductions were concentrated in inpatient, intermediate, and ambulatory care, as well as medication use. Being offered an HDHP was associated with a decrease of 21% (P < .001) on health plan spending and an increase of 14% (P < .01) on out-of-pocket spending.

CONCLUSIONS

Offering an HDHP was associated with a reduction in SUD service use and a shift in spending from the plan to the enrollee. In the context of the US drug epidemic, these study findings highlight a concern that the movement toward HDHPs may be exacerbating undertreatment of SUD.

Scaling Interventions to Manage Chronic Disease: Innovative Methods at the Intersection of Health Policy Research and Implementation Science

Policy implementation is a key component of scaling effective chronic disease prevention and management interventions. Policy can support scale-up by mandating or incentivizing intervention adoption, but enacting a policy is only the first step. Fully implementing a policy designed to facilitate implementation of health interventions often requires a range of accompanying implementation structures, like health IT systems, and implementation strategies, like training. Decision makers need to know what policies can support intervention adoption and how to implement those policies, but to date research on policy implementation is limited and innovative methodological approaches are needed. In December 2021, the Johns Hopkins ALACRITY Center for Health and Longevity in Mental Illness and the Johns Hopkins Center for Mental Health and Addiction Policy convened a forum of research experts to discuss approaches for studying policy implementation. In this report, we summarize the ideas that came out of the forum. First, we describe a motivating example focused on an Affordable Care Act Medicaid health home waiver policy used by some US states to support scale-up of an evidence-based integrated care model shown in clinical trials to improve cardiovascular care for people with serious mental illness. Second, we define key policy implementation components including structures, strategies, and outcomes. Third, we provide an overview of descriptive, predictive and associational, and causal approaches that can be used to study policy implementation. We conclude with discussion of priorities for methodological innovations in policy implementation research, with three key areas identified by forum experts: effect modification methods for making causal inferences about how policies' effects on outcomes vary based on implementation structures/strategies; causal mediation approaches for studying policy implementation mechanisms; and characterizing uncertainty in systems science models. We conclude with discussion of overarching methods considerations for studying policy implementation, including measurement of policy implementation, strategies for studying the role of context in policy implementation, and the importance of considering when establishing causality is the goal of policy implementation research.

Association of Direct-to-Consumer Advertising of Prescription Drugs With Consumer Health-Related Intentions and Beliefs Among Individuals at Risk of Cardiovascular Disease

Importance

Consumers in the US are exposed to unprecedented high levels of direct-to-consumer advertising (DTCA) for prescription drugs, yet there is limited evidence regarding their effect on health-related intentions and beliefs.

Objective

To provide evidence on the association of DTCA for prescription drugs with consumer health-related intentions and beliefs.

Design, Setting, and Participants

This cross-sectional study recruited participants from a nationally representative sample of individuals at high risk of cardiovascular disease. Participants were randomly assigned into 1 of 3 study arms: (1) exposure to DTCA for heart disease medications (treatment 1 [n = 926]), (2) exposure to DTCA for heart disease medications with price disclosure (treatment 2 [n = 921]), (3) and exposure to nonpharmaceutical advertising (control group [n = 902]). Each study arm viewed five 1-minute video advertisements, totaling 5 minutes of advertising exposure. The 2 treatment arms viewed pharmaceutical advertising videos for 4 heart disease medications, and the control arm viewed nonpharmaceutical advertising videos. Participants then completed a survey questionnaire to measure medication- and lifestyle-related intentions and health-related beliefs and perceptions.

Exposures

Direct-to-consumer advertising for heart disease medications (treatment 1), DTCA for heart disease medications with price disclosure (treatment 2), and nonpharmaceutical advertising (control group).

Main Outcomes and Measures

The primary outcomes included ordinal measures of medication- and lifestyle-related intentions, health-related beliefs, and brand perceptions.

Results

Among the 2874 included participants (mean [SD] age, 53.8 [7.1] years; 1549 [54%] male) χ2 tests confirmed that there were no statistically significant differences in baseline demographic characteristics across study arms. There was a positive association between DTCA and medication-related behavioral intentions, including intention to switch medication (marginal effect [ME] = 0.004; P = .002) and engage in information-seeking behaviors (ME = 0.02; P = .01). There was no evidence that pharmaceutical DTCA discouraged use of nonpharmacological lifestyle interventions that can help manage heart disease (eg, diet and exercise), and DTCA exposure also had a positive association with consumers' favorable perceptions of pharmaceutical manufacturers (competence: ME = 0.03; P = .01; innovative: ME = 0.03; P = .008). There was no evidence for differential associations of price disclosures in DTCA.

Conclusions and Relevance

In this cross-sectional study, results showed that brief exposure to pharmaceutical DTCA had a large and positive association with medication-related demand intentions with no offsetting negative spillovers on lifestyle-related intentions. Lack of associations with price disclosure in DTCA suggests that policy makers should consider alternative strategies to promote value-based decision-making for prescription drugs.

Examining Health Care Access And Health Of Children Living In Homes Subsidized By The Low-Income Housing Tax Credit

Although stable, high-quality housing improves children's physical and social-emotional health, little is known about the health of children living in buildings financed by the federal government's primary tool for constructing and renovating affordable rental housing: the Low-Income Housing Tax Credit (LIHTC). Using data from the National Health Interview Survey (2004-16) linked to data on LIHTC properties (1987-2016), this study provides national estimates for health care access and health status among low-income children living in LIHTC properties compared with low-income children not living in LIHTC properties. Children living in LIHTC properties were more likely to have had a well-child visit in the past twelve months and a dental visit in the past six months. These children also had a higher likelihood of chronic school absenteeism and current asthma. These exploratory findings suggest that policy makers should consider features of LIHTC policy as possible mechanisms to improve low-income children's health care access and health status while addressing the shortage of affordable housing in the US.

Messages in prescription drug advertising for four chronic diseases, 2003-2016: A content analysis

The objective of this study was to examine the frequency and content of messages related to pharmacological and evidence-based, non-pharmaceutical treatments in direct-to-consumer advertising (DTCA) for prescription drugs treating four chronic diseases in the United States. We used content coding to identify theory-informed categories of messages appearing in a large sample of heart disease, diabetes, depression, and osteoarthritis advertisements, appearing on national and local television between 2003 and 2016 (N = 11,347,070). The data were originally accessed in 2019 and analyzed in 2020-2021. The central message in all pharmaceutical DTCA was drug efficacy. Advertisements for diabetes and heart disease, but not depression or osteoarthritis, contained general (not central) messages about diet and exercise. Advertisements for heart disease primarily portrayed diet and exercise as insufficient for controlling the target health condition. No advertisements in our sample portrayed changes in diet or physical activity as an alternative to drugs. Pharmaceutical DTCA across health conditions employ similar strategies to promote use of the advertised drug but vary widely in whether and how they describe non-pharmaceutical treatments that complement or serve as alternatives to medications. Regulators should consider the potential spillover effects of non-pharmaceutical messages in pharmaceutical DTCA when considering future regulatory endeavors.

Effects of High-Deductible Health Plans on Enrollees With Mental Health Conditions With and Without Substance Use Disorders

OBJECTIVE

High-deductible health plans (HDHPs) are increasingly common in the U.S. health insurance market and are intended to reduce the use of low-value services, but evidence suggests that HDHP enrollees also reduce the use of high-value services. This study examined the effects of HDHPs on enrollees with mental health conditions, a population with high levels of unmet treatment need, often because of financial barriers. Enrollees with a co-occurring substance use disorder have greater treatment needs and unique barriers to care, perhaps changing their response to an HDHP.

METHODS

Commercial health insurance claims data in a difference-in-differences design was used to evaluate the effect of an employer's offer of an HDHP on 6,627,128 enrollee-years among enrollees with mental health conditions, stratified by having a co-occurring substance use disorder or not.

RESULTS

Among enrollees without a co-occurring substance use disorder, an HDHP offer was associated with a 4.8% (95% confidence interval [CI]=2.4%-7.2%) reduction in overall spending on mental health care, despite an 11.3% (95% CI=1.0%-21.6%) increase in spending on mental health-related emergency department visits. Among enrollees with a co-occurring substance use disorder, no significant changes attributable to an HDHP offer were found in most categories of spending on combined mental health and substance use disorder care, apart from a 4.5% (95% CI=1.9%-7.2%) reduction in spending on psychotropic medications.

CONCLUSIONS

HDHPs may reduce use of necessary care among enrollees with mental health conditions, which could exacerbate undertreatment in this population and result in adverse health outcomes.

Does industry self-regulation restrict advertising? Evidence from the Children's Food and Beverage Advertising Initiative

OBJECTIVE

The aim of this study was to evaluate the effectiveness of the Children's Food and Beverage Advertising Initiative (CFBAI) in reducing children's exposure to ads for candy and sweetened beverages.

METHODS

Survey data were used to determine the television programs that children watch and the time slots during which they watch television. Advertisement placement data were used to count the number of candy and sweetened beverage (SB) ads appearing on programs and during those time slots. Advertisement placement data and children's exposure measures were examined for 2003 to 2013.

RESULTS

There was a dramatic decline in children's exposure to ads for candy and SBs. The declines occurred before CFBAI implementation and occurred for each demographic group. There was no evidence that advertisers moved ads to programs watched by both children and teens/adults, i.e., programs not likely governed by the CFBAI.

CONCLUSION

There was a striking decline in ad placements and children's exposure to ads for candy and SBs, much of which occurred when the CFBAI was being negotiated. Voluntary agreements have the potential to be successful, and some gains may occur even as firms and government negotiate the agreement.

Studying how state health services delivery policies can mitigate the effects of disasters on drug addiction treatment and overdose: Protocol for a mixed-methods study

BACKGROUND

The United States is experiencing a drug addiction and overdose crisis, made worse by the COVID-19 pandemic. Relative to other types of health services, addiction treatment and overdose prevention services are particularly vulnerable to disaster-related disruptions for multiple reasons including fragmentation from the general medical system and stigma, which may lead decisionmakers and providers to de-prioritize these services during disasters. In response to the COVID-19 pandemic, U.S. states implemented multiple policies designed to mitigate disruptions to addiction treatment and overdose prevention services, for example policies expanding access to addiction treatment delivered via telehealth and policies designed to support continuity of naloxone distribution programs. There is limited evidence on the effects of these policies on addiction treatment and overdose. This evidence is needed to inform state policy design in future disasters, as well as to inform decisions regarding whether to sustain these policies post-pandemic.

METHODS

The overall study uses a concurrent-embedded design. Aims 1-2 use difference-in-differences analyses of large-scale observational databases to examine how state policies designed to mitigate the effects of the COVID-19 pandemic on health services delivery influenced addiction treatment delivery and overdose during the pandemic. Aim 3 uses a qualitative embedded multiple case study approach, in which we characterize local implementation of the state policies of interest; most public health disaster policies are enacted at the state level but implemented at the local level by healthcare systems and local public health authorities.

DISCUSSION

Triangulation of results across methods will yield robust understanding of whether and how state disaster-response policies influenced drug addiction treatment and overdose during the COVID-19 pandemic. Results will inform policy enactment and implementation in future public health disasters. Results will also inform decisions about whether to sustain COVID-19 pandemic-related changes to policies governing delivery addiction and overdose prevention services long-term.

Disparities in exposure to television advertising of sugar-sweetened and non-nutritive sweetened beverages among U.S. adults and teens, 2007-2013

The objective of this study was to estimate disparities in exposure to television advertising of sugar-sweetened and non-nutritive sweetened beverages among U.S. adults and teens. Data (2007-2013) came from the National Consumer Survey and included 115,510 adult respondents (age 18+) and 8635 teen respondents (age 12-17). The data was originally accessed in 2018 and analyzed in 2019-2020. The main outcomes were individual-level estimated exposure to advertisements for regular soda, diet soda, and energy/sport drinks. The main exposures were by race/ethnicity, household income, and educational attainment. Non-white adults (teens) were exposed to an estimated (per year) 101.5 (190.1) regular soda ads, 49.5 (61.2) diet soda ads, and 157.1 (279.6) energy/sport ads per year while white respondents were exposed to 97.5 (127.7) regular soda ads, 45.8 (44.2) diet soda ads, and 123.9 (192.0) energy/sport ads per year. Adult (teen) respondents who were non-white with low incomes and with low educational attainment were exposed to 4.7% (53.7%) more regular soda ads, 6.6% (43.8%) more diet ads, and 23.2% (56.2%) more energy/sport ads than respondents who were white with high incomes and high educational attainment. Demographic and socio-economic groups with a higher prevalence of obesity were exposed to significantly more advertisements for sugar-sweetened beverages. When evaluating potential policies to regulate marketing of sugar-sweetened and non-nutritive sweetened beverages, policymakers should consider the disparate exposure of at-risk populations to advertising of sugar-sweetened and non-nutritive sweetened beverages.

Comparison of Trends in Nonprofit Hospitals' Charity Care Eligibility Policies Between Medicaid Expansion States and Medicaid Nonexpansion States

Nonprofit hospitals provide charity care to financially disadvantaged patients according to their self-designed eligibility policies. The Affordable Care Act may have prompted nonprofit hospitals to adopt more generous eligibility policies, but no prior research has examined the longitudinal trend. The expansion of Medicaid coverage in many states has been found to reduce charity care provision, but it is unclear whether the change in charity care eligibility policies differed between Medicaid expansion and nonexpansion states. Using mandatory tax filings, we found that both hospitals in Medicaid expansion states and hospital in nonexpansion states adopted more generous eligibility policies in 2018 than in 2010, but the change was greater in the former for discounted charity care; while the former provided less charity care regardless of their policy changes, the latter provided more when their policies became more generous. This study has implications for policy discussions on the justification of nonprofit hospitals' tax-exempt status.

Large self-insured employers lack power to effectively negotiate hospital prices

OBJECTIVES

Self-insured employers cover more people than Medicare, Medicaid, or direct purchasers of private insurance.This study examined the ability of self-insured employers to negotiate hospital prices and the relationship between hospital prices and employer market power in the United States.

STUDY DESIGN

Repeated cross-section analysis of commercial claims.

METHODS

We used the US Census Bureau County Business Patterns data to estimate employer market power at the metropolitan statistical area (MSA)-year level and used the Truven Health MarketScan commercial claims to estimate mean hospital prices and price ratios at the MSA-year level (2010-2016). We calculated descriptive statistics for employer market power, mean hospitalization prices, and a case mix-adjusted price ratio measure during the study period and analyzed the 10 most concentrated labor markets. We estimated MSA-year-level ordinary least squares regressions of hospitalization price and the price ratio measure on employer market power.

RESULTS

Large self-insured employers had concentrated market power in very few MSAs in 2016. The mean value of our employer market power measure was 62 for 2016, compared with the mean value of 5410 for hospital market power in the United States. Regression analyses find a slight relationship: A 1-point increase in employer market power was associated with a $6.61 decrease in the hospitalization price (mean = $20,813), but this result becomes statistically insignificant once the models control for hospital wages.

CONCLUSIONS

Employer market power is low in most MSAs. Self-insured employers may consider building purchase alliances with state and local government employee groups to enhance their market power and lower negotiated prices for hospital services.

Analysis Suggests Government And Nonprofit Hospitals' Charity Care Is Not Aligned With Their Favorable Tax Treatment

The different tax treatment of government, nonprofit, and for-profit hospitals implies different charity care obligations, with the greatest obligation for government hospitals and the least for for-profit hospitals. Prior research has not examined charity care provision among all three ownership types at the national level. Using 2018 Medicare Hospital Cost Reports, we compared charity care provision across 1,024 government, 2,709 nonprofit, and 930 for-profit hospitals. In aggregate, nonprofit hospitals spent $2.3 of every $100 in total expenses incurred on charity care, which was less than government ($4.1) or for-profit ($3.8) hospitals. No hospital ownership type outperformed the other two types with respect to charity care provision in a majority of hospital service areas containing all three types. Using different kinds of analyses, we also found wide variation in charity care provision within ownership types and a lack of a consistent pattern across ownership types. These results suggest that many government and nonprofit hospitals' charity care provision was not aligned with their charity care obligations arising from their favorable tax treatment. Policy makers may consider initiatives to enhance hospitals' charity care provision, particularly hospitals with government and nonprofit ownership.

Frequency and Costs of Out-of-Network Bills for Outpatient Laboratory Services Among Privately Insured Patients

IMPORTANCE

Patients may be unaware of which laboratory is processing their clinical tests, limiting their ability to choose an in-network laboratory. Out-of-network laboratory services could increase patients' out-of-pocket costs and their reluctance to obtain necessary tests.

OBJECTIVE

To evaluate the frequency and cost of out-of-network bills for outpatient laboratory services compared with other services.

DESIGN, SETTING, AND PARTICIPANTS

This retrospective cohort study of claims data from the Truven MarketScan Commercial Claims database evaluated claims from 3 946 210 individuals (30.5% of the total) in the MarketScan database who were continually enrolled in health maintenance organization plans, preferred provider organization plans, exclusive provider organization plans, or consumer-driven health plans/high-deductible health plans with at least 1 outpatient clinical laboratory service in 2018. Outpatient laboratory services occurred in independent laboratories, physician offices, and outpatient centers. Laboratory bills from January 1, 2010, to December 31, 2018, were studied.

EXPOSURES

Receipt and cost of outpatient laboratory service.

MAIN OUTCOMES AND MEASURES

The primary outcome was the proportion of outpatient laboratory services billed as out of network. The secondary outcome was the total potential out-of-pocket cost associated with the out-of-network bill, the sum of observed cost sharing, and the potential balance bill.

RESULTS

Of the 12 958 130 in the total sample, 30.5% (3 946 210) had a laboratory test, of whom 5.9% received an out-of-network laboratory test. In comparison, 7.1% of the total sample had an emergency department visit, of whom 4.9% had a service billed as out of network, and 1.6% had an inpatient anesthesiology service, of whom 3.4% had an out-of-network service. Observed out-of-pocket spending was $24.59 higher for an out-of-network laboratory service than an in-network laboratory service. In addition, patients with an out-of-network laboratory service may receive an additional balance bill from the laboratory service; the estimated mean balance bill was $80.63. For the most common laboratory services, the total potential out-of-pocket cost associated with an out-of-network bill ranged from $15.68 for venipuncture to $88.09 for lipid panel but was as high as $303.18 for a drug screening test.

CONCLUSIONS AND RELEVANCE

In this cohort study, out-of-network laboratory services were 5 times more common than out-of-network emergency department visits and 34 times more common than out-of-network anesthesiology services. It is important for patients that consumer protections against out-of-network bills apply to laboratory services.

The Impact Of Academic Medical Center Policies Restricting Direct-To-Physician Marketing On Opioid Prescribing

Direct-to-physician opioid marketing by pharmaceutical companies is widespread and may contribute to opioid overprescribing, an important driver of the US opioid crisis. Using a difference-in-differences approach and Medicare Part D prescriber data, we examined the effects of academic medical centers' conflict-of-interest policies that restrict direct-to-physician marketing of all drugs on opioid prescribing by physicians at eighty-five centers in the period 2013-16. We examined restrictions on gifts and meals, speaking and consulting engagements, and industry representatives' access to academic medical centers, as well as rules requiring conflict-of-interest disclosures. Bans on sales representatives were associated with a 4.7 percent reduction in the total volume of opioids prescribed and disclosure requirements with a 2.5 percent reduction, while having all four marketing restriction policies was associated with an 8.8 percent reduction. Policies that restrict direct-to-physician pharmaceutical marketing may curb opioid prescribing, but additional patient-level research is needed to understand how such policies affect the delivery of evidence-based treatment for chronic pain.

Comparing the value of community benefit and Tax-Exemption in non-profit hospitals

Objective

We examined the characteristics of non‐profit hospitals providing more community benefits and charity care than value of their tax exemptions and how this relationship changed between 2011 and 2018.

Data sources

Primary dataset was schedule H Form IRS 990 data. This data was merged with the American Hospital Association, Medicare Hospital Cost Report, and the America Community Survey.

Study design

We measured six categories of tax benefits and 17 types of community benefits. Subtracting the average value of community benefits provided by for‐profit hospitals, we computed incremental community benefit and charity care provided by each non‐profit hospital.

Extraction methods

A nationally representative sample was created of 11 776 non‐profit hospital‐year observations from 1472 unique hospitals over the 2011 to 2018 period was created. Descriptive analyses and random effect logistic regression were used to show associations between hospital characteristics and difference between incremental net community benefits and the value of tax‐exemption.

Principal findings

After adjusting for community benefits provided by for‐profits hospitals, on average, non‐profit hospitals spent 5.9% (CI: 5.8%‐6.0%) of their total expenses on community benefits; 1.3% (CI: 1.2%‐1.3%) on charity care; and received 4.3% (CI: 4.2%‐4.4%) of total expenses in tax exemptions. A total of 38.5% of non‐profit hospitals did not provide more community benefit and 86% did not provide more charity care than the value of their tax exemption. Hospitals with fewer beds, providing residency education and located in high poverty communities were more likely to provide more incremental community benefits and charity care than the value of their tax exemption, while system affiliation had a negative association.

Conclusion

The amount of community benefits and charity care provided by non‐profits varied substantially across non‐profit hospitals. Establishing minimum requirements for non‐profit hospitals or publicly ranking hospitals based on their community benefit or charity care contributions, could encourage greater community benefits and charity care.

Labor Market Concentration and Worker Contributions to Health Insurance Premiums

In concentrated labor markets, where workers have fewer employers to choose from, employers may exploit their monopsony power by contributing less to workers' health benefits. This study examined if labor market concentration was associated with higher worker contributions to health plan premiums. We combined publicly available data from the Census to calculate labor market concentration and the Medical Expenditure Panel Survey Insurance/Employer Component to determine premium contributions from 2010 to 2016 for metropolitan areas. After controlling for year fixed-effects and market characteristics, we found that higher labor market concentration was associated with higher worker contributions to health plan premiums, lower take-home income, and no change in employer contributions to premiums, consistent with the hypothesis that greater labor market concentration is associated with less generous health benefits. When evaluating the effects of mergers and acquisitions on labor markets, regulatory agencies should critically assess worker contributions to health insurance premiums.

Effects of employer-offered high-deductible plans on low-value spending in the privately insured population

Enrollment in plans with high deductibles has increased more than seven-fold in the last decade. Proponents of these plans argue that high deductibles could reduce wasteful spending by providing patients with incentives to limit use of low-value services that offer little or no clinical benefit. Others are concerned that patients may respond to these incentives by reducing their use of medical services indiscriminately and regardless of clinical benefit, which may negatively impact health outcomes. This study uses individual-level insurance claims data (2008-2013) and plausibly exogenous changes in plan offerings within firms over time to estimate the intent-to-treat and local-average treatment effects of high-deductible plan offerings on spending on 24 low-value services received in the outpatient setting. We find that firm offer of a high-deductible plan leads to a 13.7% ($5.23) reduction in average enrollee spending on low-value outpatient services and a 5.2% ($105.77) reduction in overall outpatient spending. We also find reductions in spending on measures of low-value imaging and laboratory services. We find some evidence that offering high-deductible plans disproportionately reduces low-value spending relative to overall spending, indicating that deductibles may be a way to incentivize value-based decision making.

Financial Risk for COVID-19-like Respiratory Hospitalizations in Consumer-Directed Health Plans

INTRODUCTION

This study aims to quantify out-of-pocket spending associated with respiratory hospitalizations for conditions similar to those caused by coronavirus disease 2019 and to compare out-of-pocket spending differences among those enrolled in consumer-directed health plans and in traditional, low-deductible plans.

METHODS

This study used deidentified administrative claims from the OptumLabs Data Warehouse (January 1, 2016-August 31, 2019) to identify patients with a respiratory hospitalization. It compared unadjusted out-of-pocket spending among consumer-directed health plan enrollees with that among traditional plan enrollees using difference of mean significance tests and repeated the analysis separately by age category and calendar year quarter. These data were collected on a rolling basis by OptumLabs and were analyzed in March 2020.

RESULTS

Commercially insured consumer-directed health plan enrollees had significantly higher out-of-pocket spending than traditional plan enrollees, and these differences were largest among younger populations. The largest difference in out-of-pocket spending occurred during the first half of the year.

CONCLUSIONS

Consumer-directed health plan enrollees may experience differential financial burden from a hospitalization related to coronavirus disease 2019. Although some insurers are waiving cost-sharing payments for coronavirus disease 2019 treatment, self-insured employers remain exempt. As of now, policy responses may be insufficient to reduce the financial burden on consumer-directed health plans enrollees with respiratory hospitalizations related to coronavirus disease 2019.

Health Care Spending by Enrollees With Substance Use and Mental Health Disorders in High-Deductible Health Plans vs Traditional Plans

This cross-sectional study compares health care spending among high-deductible health plan vs traditional plan enrollees with substance use and mental health disorders.

Opioid overdose death following criminal justice involvement: Linking statewide corrections and hospital databases to detect individuals at highest risk

BACKGROUND

Persons who interact with criminal justice and hospital systems are particularly vulnerable to negative health outcomes, including overdose. However, the relationship between justice involvement, healthcare utilization and overdose risk is not well-understood. This data linkage study seeks to improve our understanding of the link between different types of justice involvement as well as hospital interaction and risk of fatal opioid overdose among persons with incarcerations, arrests and parole/probation records for drug and property crimes in Maryland.

METHODS

Maryland statewide criminal justice records were obtained for 2013-2016. Data were linked at the person-level to an all-payer hospitalization database and overdose death records for the same years. Logistic regression was performed to determine which criminal justice and hospital characteristics were associated with greatest risk of overdose death.

RESULTS

89,591 adults had criminal-justice records and were included in the study. During the 2013-2016 study period, 4108 (4.59 %) were hospitalized for a non-fatal opioid overdose, and 519 (0.58 %) died of opioid overdose. Strongest risk factors for death included being older, being white, having had an inpatient or emergency hospitalization, having had more arrests, having been arrested for a drug charge (vs. property charge), having a misdemeanor drug charge (vs. a felony charge), and having been released from incarceration during the study period.

CONCLUSION

Linking corrections and healthcare information can help advance understanding of risk and target overdose prevention interventions directed at justice-involved individuals with greatest need.

Association Between Treatment by Fraud and Abuse Perpetrators and Health Outcomes Among Medicare Beneficiaries

IMPORTANCE

Fraud and abuse contribute to unnecessary spending in the Medicare program, and federal agencies have prioritized fund recovery and the exclusion of health care practitioners who violate policy. However, the human costs of fraud and abuse in terms of patient health are unknown.

OBJECTIVE

To assess whether Medicare beneficiaries' receipt of health care services from fraud and abuse perpetrators (FAPs) is associated with worse health outcomes.

DESIGN, SETTING, AND PARTICIPANTS

Retrospective cross-sectional study comparing mortality and emergency hospitalization rates of 8204 patients treated by an FAP with those among patients treated by a randomly selected non-FAP in 2013. Known FAPs were identified from the December 2018 List of Excluded Individuals/Entities (LEIE) published by the Office of the Inspector General in the Department of Health and Human Services. Patients were identified in a 5% sample of Medicare claims data and were enrolled in the Fee-for-Service program.

EXPOSURES

Treatment by a health care professional subsequently excluded from Medicare for fraud, patient harm, or a revoked license.

MAIN OUTCOMES AND MEASURES

All-cause mortality between 2013 and 2015 and 2013 emergency hospitalizations.

RESULTS

A total of 8204 Medicare beneficiaries in the study sample (mean [SD] age, 69.2 [14.2] years; 58.2% female, and 23.0% nonwhite) saw an FAP for the first time in 2013. Of these, 5054 (61.6%) were treated by fraud perpetrators, 1157 (14.1%) by patient harm perpetrators, and 1193 (24.3%) by revoked license perpetrators. Compared with 296 298 beneficiaries treated by non-FAPs (mean [SD] age, 71.1 [12.4] years; 58.6% female, and 16.5% nonwhite), beneficiaries exposed to an FAP were more likely to be eligible for both Medicare and Medicaid (34.7% [2845 of 8204] vs 21.9% [64 989 of 296 298]; P < .001) and more likely to be disabled at an age younger than 65 years (27.2% [2231 of 8204] vs 18.6% [55 168 of 296 298]; P < .001). All FAP exposures were associated with higher mortality and emergency hospitalization rates after risk adjustment and propensity score weighting: for mortality, exposures to fraud FAPs were associated with an increase of 4.58 percentage points (95% CI, 2.02-7.13; P < .001); to patient harm FAPs, with an increase of 3.34 percentage points (95% CI, 1.40-5.27; P = .001); and to revoked license FAPs, with an increase of 3.33 percentage points (95% CI, 1.58-5.09; P < .001). Increases were similar for emergency hospitalization rates: for fraud FAP exposures, 3.24 percentage points (95% CI, 0.01-6.46; P = .049); for patient harm FAP exposures, 9.34 percentage points (95% CI, 6.02-12.65; P < .001); and for revoked license FAP exposures, 9.28 percentage points (95% CI, 6.43-12.13; P < .001).

CONCLUSIONS AND RELEVANCE

This study's findings suggest that receiving medical care from FAPs may be associated with significantly higher rates of all-cause mortality and emergency hospitalization after risk adjustment. Identifying and permanently removing FAPs from the Medicare program may be associated with improved beneficiary health in addition to financial savings.

Predicting Opioid Overdose Deaths Using Prescription Drug Monitoring Program Data

INTRODUCTION

Prescription Drug Monitoring Program data can provide insights into a patient's likelihood of an opioid overdose, yet clinicians and public health officials lack indicators to identify individuals at highest risk accurately. A predictive model was developed and validated using Prescription Drug Monitoring Program prescription histories to identify those at risk for fatal overdose because of any opioid or illicit opioids.

METHODS

From December 2018 to July 2019, a retrospective cohort analysis was performed on Maryland residents aged 18-80 years with a filled opioid prescription (n=565,175) from January to June 2016. Fatal opioid overdoses were identified from the Office of the Chief Medical Examiner and were linked at the person-level with Prescription Drug Monitoring Program data. Split-half technique was used to develop and validate a multivariate logistic regression with a 6-month lookback period and assessed model calibration and discrimination.

RESULTS

Predictors of any opioid-related fatal overdose included male sex, age 65-80 years, Medicaid, Medicare, 1 or more long-acting opioid fills, 1 or more buprenorphine fills, 2 to 3 and 4 or more short-acting schedule II opioid fills, opioid days' supply ≥91 days, average morphine milligram equivalent daily dose, 2 or more benzodiazepine fills, and 1 or more muscle relaxant fills. Model discrimination for the validation cohort was good (area under the curve: any, 0.81; illicit, 0.77).

CONCLUSIONS

A model for predicting fatal opioid overdoses was developed using Prescription Drug Monitoring Program data. Given the recent national epidemic of deaths involving heroin and fentanyl, it is noteworthy that the model performed equally well in identifying those at risk for overdose deaths from both illicit and prescription opioids.

Vitamin panacea: Is advertising fueling demand for products with uncertain scientific benefit?

This study examines the effect of advertising on demand for vitamins-products with spiraling sales despite little evidence of efficacy. We merge seven years (2003-2009) of advertising data from Kantar Media with the Simmons National Consumer Survey to estimate individual-level vitamin print and television ad exposure effects. Identification relies on exploiting exogenous variation in year-to-year advertising exposure by controlling for each individual's unique media consumption. We find that increasing advertising exposure from zero to the mean number of ads increases the probability of consumption by 1.2 and 0.8% points (or 2 and 1.4%) in print and television respectively. Stratifications by the presence of health conditions suggests that in print demand is being driven by both healthy and sick individuals.

The long term effects of "Consumer-Directed" health plans on preventive care use

"Consumer-Directed" Health Plans (CDHPs), those with high deductibles and personal medical accounts, have been shown to reduce health care spending. The impact of CDHPs on preventive care is unclear. On the one hand CDHPs might increase use of preventive care as such care is exempt from the deductible. However, CDHPs also decrease visits to physicians which might results in less screening. Prior research has found conflicting results. In this study, using data from 37 employers we examine the effects of CDHPs on the use of cancer screenings up to three years after the initial CDHP offering with ITT and LATE approaches. Being offered a CDHP or enrolling in a CDHP had little or no effect on cancer screening rates but individuals increase screenings prior to enrolling in a CDHP. Our findings suggest the importance of examining CDHP effects on periodic care over the longer-term and carefully controlling for anticipatory stockpiling.

An examination of structure-function claims in dietary supplement advertising in the U.S.: 2003-2009

Dietary supplement advertising cannot claim a causal link between the product and the treatment, prevention, or cure of a disease unless manufacturers seek approval from the FDA for a health claim. Manufacturers can make structure-function (S-F) claims without FDA approval linking a supplement to a body function or system using words such as "may help" or "promotes." These S-F claims are examined in this study in order to determine whether they mimic health claims for which the FDA requires stricter scientific evidence. Data include S-F claims in supplement advertisements (N=6179) appearing in US nationally circulated magazines (N=137) from 2003 to 2009. All advertisements were comprehensively coded for S-F claims, seals of approval, and other claims of guarantee. S-F claims associate supplements with a wide variety of health conditions, many of which are serious diseases and/or ailments. A significant number of the specific verbs used in these S-F claims are indicative of disease treatment/cure effects, thereby possibly mimicking health claims to the average consumer. The strength of the clinical associations made are largely unsubstantiated in the medical literature. Claims that a product is "scientifically proven" or "guaranteed" were largely unsubstantiated by clinical literature. Ads carrying externally validating seals of approval were highly prevalent. S-F claims that strongly mimic FDA-prohibited health claims are likely to create confusion in interpretation and possible public health concerns are discussed.

Do "Consumer-Directed" health plans bend the cost curve over time?

"Consumer-Directed" Health Plans (CDHPs), those with high deductibles and personal medical accounts, are intended to reduce health care spending through greater patient cost exposure. Prior research agrees that in the first year, CDHPs reduce spending. There is little research and in it results are mixed regarding the impact of CDHPs over the longer term. We add to this literature with an intent-to-treat, difference-in-differences analysis of health care spending over up to three years post CDHP offer among 13 million person-years of data from 54 large US firms, half of which offered CDHPs. To strengthen the identification, we balance observables over time within firm, by developing weights through a machine learning algorithm, generalized boosted regression. We find that spending is reduced for those in firms offering CDHPs in all three years post offer relative to firms continuing to offer lower-deductible plans. The reductions are driven by spending decreases in outpatient care and pharmaceuticals, with no evidence of increases in emergency department or inpatient care over the three-year window.

The impact of direct-to-consumer television and magazine advertising on antidepressant use

We examine whether exposure to direct-to-consumer advertising (DTCA) for antidepressant drugs affects individual use of these medications among those suffering from depression. Prior studies have almost exclusively relied on making connections between national or market-level advertising volume/expenditures and national or individual-level usage of medications. This is the first study to: estimate the impact of individual-level exposure to DTCA on individual-level use of antidepressants; estimate the impact of individual-level exposure to television DTCA on individual-level use in any drug class; consider the relative and interactive impact of DTCA in two different media in any drug class; and, consider the heterogeneity of impact among different populations in an econometric framework in the antidepressant market. There are also important limitations to note. Unlike prior market level studies that use monthly data, we are limited to aggregated annual data. Our measures of potential advertising exposure are constructed assuming that media consumption patterns are stable during the year. We are also not able to study the impact of advertising on use of antidepressants for conditions other than depression, such as anxiety disorders. We find that: DTCA impacts antidepressant use in a statistically and economically significant manner; that these effects are present in both television and magazine advertising exposure but do not appear to have interactive effects; are stronger for women than for men in the magazine medium, but are about equally strong for men and women in the TV medium; and, are somewhat stronger for groups suffering from more severe forms of depression. The overall size of the effect is a 6-10 percentage point increase in antidepressant use from being exposed to television advertising; the corresponding magazine effects are between 3 and 4 percentage points.