Rural and frontier access to mental health prescribers and nonprescribers: A geospatial analysis in Oregon Medicaid.

OBJECTIVE: Medicaid enrollees in rural and frontier areas face inadequate access to mental health services, but the extent to which access varies for different provider types is unknown. We assessed access to Medicaid-participating prescribing and nonprescribing mental health clinicians, focusing on Oregon, which has a substantial rural population. METHODS: Using 2018 Medicaid claims data, we identified enrollees aged 18-64 with psychiatric diagnoses and specialty mental health providers who billed Medicaid at least once during the study period. We measured both 30- and 60-minute drive time to a mental health provider, and a spatial access score derived from the enhanced 2-step floating catchment area (E2SFCA) approach at the level of Zip Code Tabulation Areas (ZCTAs). Results were stratified for prescribers and nonprescribers, across urban, rural, and frontier areas. RESULTS: Overall, a majority of ZCTAs (68.6%) had at least 1 mental health prescriber and nonprescriber within a 30-minute drive. E2SFCA measures demonstrated that while frontier ZCTAs had the lowest access to prescribers (84.3% in the lowest quintile of access) compared to other regions, some frontier ZCTAs had relatively high access to nonprescribers (34.3% in the third and fourth quartiles of access). CONCLUSIONS: Some frontier areas with relatively poor access to Medicaid-participating mental health prescribers demonstrated relatively high access to nonprescribers, suggesting reliance on nonprescribing clinicians for mental health care delivery amid rural workforce constraints. Efforts to monitor network adequacy should consider differential access to different provider types, and incorporate methods, such as E2SFCA, to better account for service demand and supply.

State- and County-Level Geographic Variation in Opioid Use Disorder, Medication Treatment, and Opioid-Related Overdose Among Medicaid Enrollees.

Importance: The opioid crisis disproportionately affects Medicaid enrollees, yet little systematic evidence exists regarding how prevalence of and health care utilization for opioid use disorder (OUD) vary across geographical areas. Objectives: To characterize state- and county-level variation in claims-based prevalence of OUD and rates of medication treatment for OUD and OUD-related nonfatal overdose among Medicaid enrollees. Design, Setting, and Participants: This cross-sectional study used data from the Transformed Medicaid Statistical Information System Analytic Files from January 1, 2016, to December 31, 2018. Participants were Medicaid enrollees with or without OUD in 46 states; Washington, DC; and Puerto Rico who were aged 18 to 64 years and not dually enrolled in Medicare. The analysis was conducted between September 2022 and April 2023. Exposure: Calendar-year OUD prevalence. Main Outcomes and Measures: The main outcomes were claims-based measures of OUD prevalence and rates of medication treatment for OUD and opioid-related nonfatal overdose. Individual records were aggregated at the state and county level, and variation was assessed within and across states. Results: Of the 76 390 817 Medicaid enrollee-year observations included in our study (mean [SD] enrollee age, 36.5 [1.6] years; 59.0% female), 2 280 272 (3.0%) had a claims-based OUD (mean [SD] age, 38.9 [3.6] years; 51.4% female). Of enrollees with OUD, 41.2% were eligible due to Medicaid expansion, 46.4% had other substance use disorders, 55.8% had mental health conditions, 55.2% had claims indicating some form of OUD medication, and 5.8% had claims indicating an overdose during a calendar year. Claims-based outcomes exhibited substantial variation across states: OUD prevalence ranged from 0.6% in Arkansas and Puerto Rico to 9.7% in Maryland, rates of OUD medication treatment ranged from 17.7% in Kansas to 82.8% in Maine, and rates of overdose ranged from 0.3% in Mississippi to 10.5% in Illinois. Pronounced variation was also found within states (eg, OUD prevalence in Maryland ranged from 2.2% in Prince George's County to 21.6% in Cecil County). Conclusions and Relevance: In this cross-sectional study of Medicaid enrollees from 2016 to 2018, claims-based prevalence of OUD and rates of OUD medication treatment and opioid-related overdose varied substantially across and within states. Further research appears to be needed to identify important factors influencing this variation.

State Policy and the Breadth of Buprenorphine-Prescriber Networks in Medicaid Managed Care.

Provider networks in Medicaid Managed Care (MMC) play a crucial role in ensuring access to buprenorphine, a highly effective treatment for opioid use disorder. Using a difference-in-differences approach that compares network breadth across provider specialties and market segments within the same state, we investigated the association between three Medicaid policies and the breadth of MMC networks for buprenorphine prescribers: Medicaid expansion, substance use disorder (SUD) network adequacy criteria, and SUD carveouts. We found that both Medicaid expansion and SUD network adequacy criteria were associated with substantially increased breadth in buprenorphine-prescriber networks in MMC. In both cases, we found that the associations were largely driven by increases in the network breadth of primary care physician prescribers. Our findings suggest that Medicaid expansion and SUD network adequacy criteria may be effective strategies at states' disposal to improve access to buprenorphine.

Association of Pharmacist Prescription of Contraception With Breaks in Coverage.

OBJECTIVE: To assess whether pharmacist prescription of combined hormonal contraception is associated with 12-month contraceptive continuation rates or breaks in contraceptive coverage. METHODS: We conducted a retrospective cohort study of all short-acting, hormonal contraceptive users (pill, patch, ring, injectable) in Oregon's All Payer All Claims database from January 1, 2016, to December 31, 2018. We captured contraceptive use using diagnosis and National Drug Classification codes. We used logistic regression to measure the association between prescription by a pharmacist and 12-month contraceptive continuation rates and breaks in contraceptive coverage. Model covariates included age, rurality, and payer. RESULTS: Our study sample consisted of 172,325 contraceptive users, of whom 1,512 (0.9%) received their prescriptions from a pharmacist. Pharmacists were significantly more likely than clinicians to prescribe to women between the ages of 25 and 34 years (50.5% vs 36.9%, P<.05), in urban settings (88.4% vs 81.7%, P<.05), and with commercial insurance (89.2% vs 59.5%, P<.05). We found that the rate of 12 months contraceptive continuation was higher among the population receiving a pharmacist prescription (34.3% vs 21.0%, P<.01). In an adjusted model, the odds of contraceptive continuation at 12 months were 61.0% higher for individuals with any pharmacist prescription (adjusted odds ratio [aOR] 1.61, 95% CI 1.44-1.79) compared with those with clinician prescriptions. Over 6 months, most contraceptive users in both groups experienced a break in coverage, defined as a gap of 1-29 days between prescriptions (61.6% vs 61.9%, P=.89). Breaks in contraceptive use were not significantly associated with prescriber type (aOR 1.03, 95% CI 0.90-1.18). CONCLUSION: Compared with clinician prescriptions, pharmacist prescription of contraception is associated with increased odds of 12-month contraceptive continuation rates. However, the frequency of breaks in contraceptive coverage was similar among pharmacist and clinic-based prescribers. FUNDING SOURCE: Arnold Ventures.

Medical contraindications to combined hormonal contraceptive use among women using methods prescribed by a pharmacist.

OBJECTIVE: To determine whether pharmacist prescription of combined hormonal contraception is associated with inappropriate prescription to women with medical contraindications. STUDY DESIGN: We conducted a retrosopective cohort study of all short-acting, hormonal contraceptive users (pill, patch, ring, injectable) in Oregon's All Payer All Claims database from January 1, 2016 to December 31, 2018. Our primary outcome was the proportion of women receiving a combined hormonal method who had a Medical Eligibility Category (MEC) 3 or 4 condition. We identified potential contraindications using International Classification of Disease codes. We conducted descriptive analyses of contraindication prevalence and prescription error rate by prescriber type. We used a multivariable logistic regression model to test the association between pharmacist prescriber and population characteristics. RESULTS: Our study sample consisted of 439,240 contraceptive users, of which 3782 (0.86%) received their prescriptions from a pharmacist. Women aged 25 to 29 were more likely than women over age 35 to receive contraception from a pharmacist (adjusted odds ratio (aOR) 2.74, 95% confidence interval [CI] 2.44-3.08). Pharmacist prescriptions were slightly less likely in rural areas (aOR 0.78, 95% CI 0.69-0.89) and among women on Medicaid, relative to those with commercial insurance (aOR 0.21, 95% CI 0.19-0.24). Among women given contraception in a clinical setting, 4.25% had evidence of an MEC 3 or 4 contraindication, compared to 0.9% for women seen by a pharmacist. Rates of prescribing a combined method to women with a potential contraindication were not meaningfully different by prescriber type (2.16% for clinicians vs 0.74% for pharmacists). CONCLUSION: Rates of contraceptive prescribing with a contraindication were relatively low and did not differ between clinicians and pharmacists. IMPLICATIONS: Pharmacists can safely screen for medical contraindications to combined hormonal contraception.