RESUMO
BACKGROUND: Many clients with substance use disorders (SUD) have multiple admissions to a 24-hour level of care for detoxification without ever progressing to SUD treatment. In the US, health insurers have become concerned about the high costs and ineffective results of repeat detox admissions. For other diseases, health systems increasingly target high-risk, high-cost patients with individually tailored interventions delivered by `navigators' who help patients negotiate the complex health care system. Patient incentives are another increasingly common intervention. AIMS OF THE STUDY: (i) To examine how health care spending was affected by an intervention intended to improve entry to SUD treatment among clients who had multiple detox admissions. (ii) To see whether spending effects, overall and by type of service, differed by intervention arm. (iii) To assess whether the intervention resulted in net savings from the payer perspective, after subtracting implementation costs. METHODS: The intervention was implemented in a segment of the Massachusetts Medicaid population, and used Recovery Support Navigators (RSNs) who were trained to effectively engage and connect clients with SUD to follow-up care and community resources. Services were funded using a flat daily rate per client. Additionally, in one of the two intervention arms, clients were offered successive incentive payments for meeting pre-specified milestones to reinforce recovery-oriented behaviors. For this paper, multivariate analyses of claims and administrative data were used to measure the intervention's effect on health care spending, and to estimate net savings to the payer. RESULTS: Health care spending grew 1.6 percentage points more slowly for intervention-enrolled members than for others, implying gross savings of $68 per member per month. After subtracting intervention-related costs, net savings were estimated at $57 per member per month. The intervention was also associated with shifts in the health care service mix from more to less acute settings. DISCUSSION: While the results for total spending did not reach statistical significance, they suggest some potential for insurers to reduce the health care costs associated with repeat detox utilization by using a navigator-based intervention. Analyses reported elsewhere found that this intervention had favorable effects on rates of initiation of SUD treatment. Limitations of the study include the fact that neither subjects nor sites were randomized between study groups; lack of data on crime or productivity outcomes; low participant use of RSN services; and a policy change which altered the participant pool and truncated follow-up for some. IMPLICATIONS FOR HEALTH CARE PROVISION AND USE: These results suggest some potential for payers to reduce the health care costs associated with repeat detox by using a navigator-based intervention. To the extent that this results in shifting resources from repeat detox to actual treatment, the result should provide longer term benefit to the population coping with SUD. IMPLICATIONS FOR HEALTH POLICY: These results may encourage Medicaid and other payers to further experiment with similar interventions using navigators to decrease health care costs and improved the lives of SUD patients. IMPLICATIONS FOR FURTHER RESEARCH: It could be informative to test similar navigator interventions for detox patients in other settings where enrollment periods are longer.
Assuntos
Continuidade da Assistência ao Paciente , Custos de Cuidados de Saúde/estatística & dados numéricos , Medicaid/economia , Navegação de Pacientes , Transtornos Relacionados ao Uso de Substâncias/economia , Transtornos Relacionados ao Uso de Substâncias/reabilitação , Redução de Custos , Gastos em Saúde , Humanos , Massachusetts , Navegação de Pacientes/economia , Navegação de Pacientes/métodos , Navegação de Pacientes/estatística & dados numéricos , Estados UnidosRESUMO
BACKGROUND: Unhealthy drug use is a concern in many settings, including military and veteran populations. In 2013, the Veterans Health Administration (VHA) medical center in Bedford, Massachusetts, started requiring routine screening for unhealthy drug use in outpatient primary care and mental health settings, using a validated single question. METHODS: This study used descriptive and multivariable analyses of VHA electronic records for patients eligible for the screening program (N = 16,118). The study assessed first-year rates and predictors of screening and of positive screens, both for drug use and for unhealthy alcohol use, for which screening was already required. RESULTS: During the first year, 70% of patients were screened for unhealthy drug use and 84% were screened for unhealthy alcohol use. In multivariable analyses, screening for drug use was more likely for patients who had 8 or more days with VHA visits or were aged 40 or over. Patients with a prior drug use disorder diagnosis were much less likely to be screened. Three percent of patients screened for unhealthy drug use had a positive screen, and 14% of those screened for unhealthy alcohol use had a positive screen. Strong predictors of a positive drug use screen included a prior-year diagnosis of drug use disorder, any mental health clinic visits, younger age, or being unmarried. CONCLUSIONS: The drug screening initiative was relatively successful in its first-year implementation, having screened 70% of eligible subjects. However, it failed to screen many of those most likely to screen positive, thereby missing many opportunities to address unhealthy drug use. Future refinements should include better training clinicians in how to ask sensitive questions and how to address positive screens.
Assuntos
Programas de Rastreamento/estatística & dados numéricos , Pacientes Ambulatoriais/estatística & dados numéricos , Transtornos Relacionados ao Uso de Substâncias/epidemiologia , United States Department of Veterans Affairs , Saúde dos Veteranos/estatística & dados numéricos , Adolescente , Adulto , Fatores Etários , Idoso , Idoso de 80 Anos ou mais , Feminino , Humanos , Masculino , Massachusetts/epidemiologia , Pessoa de Meia-Idade , Avaliação de Programas e Projetos de Saúde , Estudos Retrospectivos , Fatores de Risco , Estados Unidos , Adulto JovemRESUMO
Health plan policies can influence delivery of integrated behavioral health and general medical care. This study provides national estimates for the prevalence of practices used by health plans that may support behavioral health integration. Results indicate that health plans employ financing and other policies likely to support integration. They also directly provide services that facilitate integration. Behavioral health contracting arrangements are associated with use of these policies. Delivery of integrated care requires systemic changes by both providers and payers thus health plans are key players in achieving this goal.
Assuntos
Seguro Saúde/organização & administração , Transtornos Mentais/terapia , Serviços de Saúde Mental/organização & administração , Administração de Caso/organização & administração , Continuidade da Assistência ao Paciente/organização & administração , Prática Clínica Baseada em Evidências , Humanos , Seguro Saúde/economia , Reembolso de Seguro de Saúde , Serviços de Saúde Mental/economia , Políticas , Atenção Primária à Saúde/organização & administração , Transtornos Relacionados ao Uso de Substâncias/terapia , Integração de Sistemas , Estados UnidosRESUMO
BACKGROUND: Private health insurance plays a large role in the U.S. health system, including for many individuals with depression. Private insurers have been actively trying to influence pharmaceutical utilization and costs, particularly for newer and costlier medications. The approaches that insurers use may have important effects on patients' access to antidepressant medications. AIMS OF THE STUDY: To report which approaches (e.g., tiered copayments, prior authorization, and step therapy) commercial health plans are employing to manage newer antidepressant medications, and how the use of these approaches has changed since 2003. METHODS: Data are from a nationally representative survey of commercial health plans in 60 market areas regarding alcohol, drug abuse and mental health services in 2010. Responses were obtained from 389 plans (89% response rate), reporting on 925 insurance products. For each of six branded antidepressant medications, respondents were asked whether the plan covered the medication and if so, on what copayment tier, and whether it was subject to prior authorization or step therapy. Measures of management approach were constructed for each medication and for the group of medications. Bivariate and multivariate analyses were used to test for association of the management approach with various health plan characteristics. RESULTS: Less than 1% of health plan products excluded any of the six antidepressants studied. Medications were more likely to be subjected to restrictions if they were newer, more expensive or were reformulations. 55% of products used placement on a high cost-sharing tier (3 or 4) as their only form of restriction for newer branded antidepressants. This proportion was lower than in 2003, when 71% of products took this approach. In addition, only 2% of products left all the newer branded medications unrestricted, down from 25% in 2003. Multivariate analysis indicated that preferred provider organizations were more likely than other product types to use tier 3 or 4 placement. DISCUSSION: We find that U.S. health plans are using a variety of strategies to manage cost and utilization of newer branded antidepressant medications. Plans appear to be finding that approaches other than exclusion are adequate to meet their cost-management goals for newer branded antidepressants, although they have increased their use of administrative restrictions since 2003. Limitations include lack of information about how administrative restrictions were applied in practice, information on only six medications, and some potential for endogeneity bias in the regression analyses. CONCLUSION: This study has documented substantial use of various restrictions on access to newer branded antidepressants in U.S. commercial health plans. Most of these medications had generic equivalents that offered at least some substitutability, reducing access concerns. At the same time, it is worth noting that high copayments and administrative requirements can nonetheless be burdensome for some patients. IMPLICATIONS FOR HEALTH POLICY: Health plans' pharmacy management approaches may concern policymakers less than in the early 2000s, due to the lesser distinctiveness of today's branded medications. This may change depending on future drug introductions. IMPLICATIONS FOR FURTHER RESEARCH: Future research should examine the impact of plans' pharmacy management approaches, using patient-level data.
Assuntos
Antidepressivos/economia , Antidepressivos/uso terapêutico , Custos de Medicamentos/estatística & dados numéricos , Planos de Seguro com Fins Lucrativos/economia , Seguro de Serviços Farmacêuticos/economia , Setor Privado/economia , Citalopram/economia , Citalopram/uso terapêutico , Controle de Custos/economia , Custo Compartilhado de Seguro/economia , Succinato de Desvenlafaxina/economia , Succinato de Desvenlafaxina/uso terapêutico , Uso de Medicamentos , Cloridrato de Duloxetina/economia , Cloridrato de Duloxetina/uso terapêutico , Fluvoxamina/economia , Fluvoxamina/uso terapêutico , Pesquisas sobre Atenção à Saúde , Acessibilidade aos Serviços de Saúde/economia , Humanos , Cobertura do Seguro/economia , Organizações de Prestadores Preferenciais/economia , Selegilina/economia , Selegilina/uso terapêutico , Estados Unidos , Cloridrato de Venlafaxina/economia , Cloridrato de Venlafaxina/uso terapêuticoRESUMO
BACKGROUND: Understanding alcohol consumption patterns of older adults with chronic illness is important given the aging baby boomer generation, the increase in prevalence of chronic conditions and associated medication use, and the potential consequences of excessive drinking in this population. OBJECTIVES: To estimate the prevalence of alcohol consumption patterns, including at-risk drinking, in older adults with at least one of seven common chronic conditions. DESIGN/METHODS: This descriptive study used the nationally representative 2005 Medicare Current Beneficiary Survey linked with Medicare claims. The sample included community-dwelling, fee-for-service beneficiaries 65 years and older with one or more of seven chronic conditions (Alzheimer's disease and other senile dementia, chronic obstructive pulmonary disease, depression, diabetes, heart failure, hypertension, and stroke; n = 7,422). Based on self-reported alcohol consumption, individuals were categorized as nondrinkers, within-guidelines drinkers, or at-risk drinkers (exceeds guidelines). RESULTS: Overall, 30.9 % (CI 28.0-34.1 %) of older adults with at least one of seven chronic conditions reported alcohol consumption in a typical month in the past year, and 6.9 % (CI 6.0-7.8 %) reported at-risk drinking. Older adults with higher chronic disease burdens were less likely to report alcohol consumption and at-risk drinking. CONCLUSIONS: Nearly one-third of older adults with selected chronic illnesses report drinking alcohol and almost 7 % drink in excess of National Institute on Alcohol Abuse and Alcoholism (NIAAA) guidelines. It is important for physicians and patients to discuss alcohol consumption as a component of chronic illness management. In cases of at-risk drinking, providers have an opportunity to provide brief intervention or to offer referrals if needed.
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Consumo de Bebidas Alcoólicas/epidemiologia , Alcoolismo/epidemiologia , Doença Crônica/psicologia , Idoso , Idoso de 80 Anos ou mais , Doença Crônica/epidemiologia , Comorbidade , Feminino , Humanos , Masculino , Medicare/estatística & dados numéricos , Prevalência , Temperança/estatística & dados numéricos , Estados Unidos/epidemiologiaRESUMO
The Substance Use and Psychological Injury Combat Study (SUPIC) will examine whether early detection and intervention for post-deployment problems among Army Active Duty and National Guard/Reservists returning from Iraq or Afghanistan are associated with improved long-term substance use and psychological outcomes. This paper describes the rationale and significance of SUPIC, and presents demographic and deployment characteristics of the study sample (N = 643,205), and self-reported alcohol use and health problems from the subsample with matched post-deployment health assessments (N = 487,600). This longitudinal study aims to provide new insight into the long-term post-deployment outcomes of Army members by combining service member data from the Military Health System and Veterans Health Administration.
Assuntos
Campanha Afegã de 2001- , Distúrbios de Guerra/epidemiologia , Distúrbios de Guerra/terapia , Guerra do Iraque 2003-2011 , Militares/psicologia , Transtornos de Estresse Pós-Traumáticos/epidemiologia , Transtornos Relacionados ao Uso de Substâncias/epidemiologia , Transtornos Relacionados ao Uso de Substâncias/terapia , Adolescente , Adulto , Distúrbios de Guerra/complicações , Distúrbios de Guerra/psicologia , Bases de Dados Factuais/estatística & dados numéricos , Diagnóstico Precoce , Feminino , Serviços de Saúde/estatística & dados numéricos , Humanos , Estudos Longitudinais , Masculino , Prevalência , Desenvolvimento de Programas , Autorrelato , Transtornos de Estresse Pós-Traumáticos/complicações , Transtornos de Estresse Pós-Traumáticos/terapia , Transtornos Relacionados ao Uso de Substâncias/complicações , Estados Unidos/epidemiologiaRESUMO
For many disorders, patient heterogeneity requires physicians to customize their treatment to each patient's needs. We test for the existence of customization in physicians' prescribing for bipolar disorder, using data from a naturalistic clinical effectiveness trial of bipolar disorder treatment (STEP-BD), which did not constrain physician prescribing. Multinomial logit is used to model the physician's choice among five combinations of drug classes. We find that our observed measure of the patient's clinical status played only a limited role in the choice among drug class combinations, even for conditions such as mania that are expected to affect class choice. However, treatment of a patient with given characteristics differed widely depending on which physician was seen. The explanatory power of the model was low. There was variation within each physician's prescribing, but the results do not suggest a high degree of customization in physicians' prescribing, based on our measure of clinical status.
Assuntos
Antipsicóticos/administração & dosagem , Transtorno Bipolar/tratamento farmacológico , Padrões de Prática Médica/estatística & dados numéricos , Adulto , Fatores Etários , Antipsicóticos/uso terapêutico , Técnicas de Apoio para a Decisão , Quimioterapia Combinada , Feminino , Humanos , Masculino , Fatores Sexuais , Fatores SocioeconômicosRESUMO
BACKGROUND: Little is known about the practitioners in managed behavioral healthcare organization (MBHO) networks who are treating mental and substance use disorders among privately insured patients in the United States. It is likely that the role of the private sector in treating behavioral health will increase due to the recent implementation of federal parity legislation and the inclusion of behavioral health as a required service in the insurance exchange plans created under healthcare reform. Further, the healthcare reform legislation has highlighted the need to ensure a qualified workforce in order to improve access to quality healthcare, and provides an additional focus on the behavioral health workforce. To expand understanding of treatment of mental and substance use disorders among privately insured patients, this study examines practitioner types, experience, specialized expertise, and demographics of in-network practitioners providing outpatient care in one large national MBHO. METHODS: Descriptive analyses used 2004 practitioner credentialing and other administrative data for one MBHO. The sample included 28,897 practitioners who submitted at least one outpatient claim in 2004. Chi-square and t-tests were used to compare findings across types of practitioners. RESULTS: About half of practitioners were female, 12% were bilingual, and mean age was 53, with significant variation by practitioner type. On average, practitioners report 15.3 years of experience (SD = 9.4), also with significant variation by practitioner type. Many practitioners reported specialized expertise, with about 40% reporting expertise for treating children and about 60% for treating adolescents. CONCLUSIONS: Overall, these results based on self-report indicate that the practitioner network in this large MBHO is experienced and has specialized training, but echo concerns about the aging of this workforce. These data should provide us with a baseline of practitioner characteristics as we enter an era that anticipates great change in the behavioral health workforce.
Assuntos
Sistemas Pré-Pagos de Saúde/estatística & dados numéricos , Programas de Assistência Gerenciada , Psiquiatria , Idoso , Feminino , Sistemas Pré-Pagos de Saúde/organização & administração , Humanos , Masculino , Programas de Assistência Gerenciada/estatística & dados numéricos , Transtornos Mentais/terapia , Serviços de Saúde Mental , Pessoa de Meia-Idade , Padrões de Prática Médica , Psiquiatria/classificação , Distribuição por Sexo , Transtornos Relacionados ao Uso de Substâncias/terapia , Recursos HumanosRESUMO
BACKGROUND: Widely accepted treatment guidelines and performance measures encourage patients to stay on antidepressant medication beyond the acute phase of treatment in order to achieve full remission and reduce risk of relapse. However, many patients discontinue antidepressant medication treatment prematurely for various reasons, including side-effects or nonresponse to the initial medication prescribed. Customization of medications to differing patient profiles could potentially improve medication treatment duration, but for many diseases physicians tend to concentrate on a limited subset of available medications. Little is known about the effects of concentration in prescribing on medication treatment duration and expenditures. AIMS OF THE STUDY: To determine the extent to which prescribing for treatment of depression is concentrated, using data from a privately insured population. To evaluate the relationship between prescribing concentration and subsequent duration of medication treatment, expenditure on medications, and the number of distinct medications used. STUDY POPULATION: Individuals receiving antidepressant treatment paid for by a large private managed behavioral health organization, in the US. METHODS: The study uses psychotropic pharmacy claims data for 2003-06 for plan members who received a depression diagnosis and had an antidepressant claim. The resulting sample includes 9,017 patients seen by 543 prescribers. For each prescriber, we compute prescribing concentration, using the Herfindahl index and the share for the three most-used medications. Treatment expenditure is computed as the sum of payments by plan and by patients. Regression analysis is used to identify the association of prescribing concentration with medication treatment duration, expenditures and other utilization measures. RESULTS: For these physicians, the mean share of the physician's total antidepressant prescribing accounted for by their three most-used regimens was 72%. The mean value of the Herfindahl index was 0.27. Over the 180-day follow-up period, the average patient had 103 days covered by antidepressant prescriptions, resulting in mean expenditures of $286, or $2.25 per day of medication supplied. Regression analysis indicates that higher concentration in a physician's prescribing was associated with fewer days of antidepressant coverage, lower medication expenditures, and subsequent use of fewer distinct medications. DISCUSSION: Higher concentration in prescribing is associated with shorter observed duration of medication treatment and lower expenditures on medications. The lower expenditures appear to be due to earlier discontinuation and fewer different medications, not to a lower cost per day supplied. Limitations of this study include lack of data on medical visits or on reasons for medication discontinuation, as the study is based on pharmacy claims data, not medical claims or surveys. In addition, it is not known whether the patient's antidepressant use represents a new episode. Finally, lack of randomization implies that the associations identified may not be causal. IMPLICATIONS FOR HEALTH CARE PROVISION AND USE: Concentration of physicians on certain medications may run counter to the increasing calls for customization of medication selection. IMPLICATIONS FOR HEALTH POLICY: Insurer policies which limit physicians' choice of medications may be lowering expenditures in part by reducing patients' medication treatment duration. IMPLICATIONS FOR FURTHER RESEARCH: Additional studies are needed to understand what mechanisms may link concentration in prescribing to medication treatment duration and expenditures.
Assuntos
Antidepressivos/administração & dosagem , Antidepressivos/economia , Transtorno Depressivo/tratamento farmacológico , Transtorno Depressivo/economia , Padrões de Prática Médica/economia , Adolescente , Adulto , Redução de Custos/estatística & dados numéricos , Relação Dose-Resposta a Droga , Esquema de Medicação , Custos de Medicamentos , Quimioterapia Combinada , Uso de Medicamentos/economia , Medicamentos Genéricos/administração & dosagem , Medicamentos Genéricos/economia , Feminino , Financiamento Pessoal/economia , Gastos em Saúde , Humanos , Seguro de Serviços Farmacêuticos/economia , Assistência de Longa Duração/economia , Masculino , Programas de Assistência Gerenciada/economia , Pessoa de Meia-Idade , Medicina de Precisão/economia , Estados Unidos , Adulto JovemRESUMO
Iraq and Afghanistan veterans experience extreme stressors and injuries during deployments, witnessing and participating in traumatic events. The military has organized prevention and treatment programs as a result of increasing suicides and posttraumatic stress disorder among troops; however, there is limited research on how to intervene with alcohol misuse and drug use that accompany these problems. This review presents statistics about post-deployment substance use problems and comorbidities, and discusses the military's dual role in 1) enforcing troop readiness with its alcohol and drug policies and resiliency-building programs, and 2) seeking to provide treatment to troops with combat-acquired problems including substance abuse.
RESUMO
BACKGROUND: Nearly half of all US workers have access to an employee assistance plan (EAP). At the same time, most large US employers also purchase health benefits for their employees, and these benefits packages typically include behavioral health services. There is some potential overlap in services covered by the EAP and the health plan, and some employers choose to purchase the two jointly as an 'integrated product'. It is not clear whether EAP services substitute for outpatient behavioral health care services covered by the health plan. AIM OF THE STUDY: To evaluate how the number of EAP visits covered affects the use of regular outpatient behavioral health care (number of visits, and total spending), in an integrated product setting. METHODS: Analysis of claims, eligibility and benefits data for 26,464 users of behavioral health care for the year 2005. For both EAP and regular behavioral health care, the individuals were enrolled with Managed Health Network (MHN), a large national specialty insurance plan. Multivariate regression analyses were performed to investigate the determinants of the number of regular outpatient visits, and spending for regular outpatient care. To address skewness in the dependent variables, the estimation used generalized linear models with a log link. A limited instrumental variable analysis was used to test for endogeneity of the number of EAP visits covered. RESULTS: Nearly half the enrollees in this sample were in employer plans that allowed 4-5 EAP visits per treatment episode, and 31% were allowed 3 EAP visits per year. Having an EAP visit allowance of 4-5 sessions per episode predicts fewer regular outpatient visits, compared with having an allowance of 3 sessions per year. More generous EAP allowances also reduce payments for outpatient care, with one exception. DISCUSSION: Greater availability of EAP benefits appears to reduce utilization of regular outpatient care, supporting the idea that the two types of care are to some extent perceived as substitutes. One limitation of this study is its cross-sectional nature, since the relationships observed could reflect the effect of other unmeasured variables. Also, the data are from a single managed behavioral health organization, limiting generalizability somewhat, although many employers are represented in the data. IMPLICATIONS FOR HEALTH POLICY: The results should discourage employers from either eliminating EAP benefits as duplicative, or replacing behavioral health benefits with an expanded EAP. Patients appear to perceive that EAP services offer something distinct from regular outpatient care. IMPLICATIONS FOR FURTHER RESEARCH: Future studies should see whether these results are reproduced, ideally by looking at employer plans with a wider range of EAP visit allowances.
Assuntos
Planos de Assistência de Saúde para Empregados/estatística & dados numéricos , Serviços de Saúde Mental/estatística & dados numéricos , Serviços de Saúde do Trabalhador/estatística & dados numéricos , Pacientes Ambulatoriais , Adolescente , Adulto , Feminino , Planos de Assistência de Saúde para Empregados/economia , Acessibilidade aos Serviços de Saúde/economia , Acessibilidade aos Serviços de Saúde/estatística & dados numéricos , Humanos , Revisão da Utilização de Seguros/estatística & dados numéricos , Masculino , Pessoa de Meia-Idade , Serviços de Saúde do Trabalhador/economia , Estados Unidos , Adulto JovemRESUMO
Although evidence points to the benefits of continuity of care after detoxification (detox), especially when continuity of care occurs within a short time after discharge from a detox episode, the rate at which clients engage in continued treatment after detox remains low. The goal of the study was to develop and deploy a specially trained workforce, called recovery support navigators (RSNs), to increase the likelihood of clients continuing onto treatment after detox. Continuity of care is defined as receiving any substance use disorder (SUD) treatment service within 14 days of discharge from the index detox. We examined whether clients in the RSN Intervention group were more likely to meet the continuity of care after detox criteria than clients in the treatment-as-usual (TAU) group. A quasi-experimental intervention versus comparison group study was conducted. Data were from the Massachusetts Behavioral Health Partnership (MBHP), a Beacon Health Options company that manages behavioral health benefits for a subset of Medicaid beneficiaries in the state. Inclusion in the analytic sample (N = 4,236) required that the client's index admission to detox was between 3/29/13 and 3/31/15. RSN Intervention versus TAU status was assigned based on provider organization where the index detox occurred. Analyses were conducted on an intent-to-treat basis. Overall, the continuity of care rate across all study groups was 42%. The rate by study group was 38% for the TAU and 45% for the RSN group. Clients who were in the RSN group were significantly more likely to have continuity of care after discharge from detox than those in the TAU (OR = 1.233, p < .05, 95% CI = 1.044, 1.455). Clients who entered detox at a site that provided specialized training to RSN, which included motivational interviewing and educational sessions related to treatment issues, and allowing them to bill with a flexible daily case rate instead of the usual fee-for-service billing, were more likely to have continuity of care after discharge from detox compared to clients in the TAU group.
Assuntos
Transtornos Relacionados ao Uso de Substâncias , Continuidade da Assistência ao Paciente , Humanos , Massachusetts , Medicaid , Motivação , Alta do Paciente , Transtornos Relacionados ao Uso de Substâncias/terapiaRESUMO
OBJECTIVES: To measure the rates and predictors of clinician recommendation for follow-up after a positive screen for unhealthy drug use, in a context of mandatory routine screening. To measure response to clinician recommendations and identification of new drug use diagnoses. METHODS: Data are from a Veterans Health Administration (VHA) medical center that introduced mandatory routine screening for unhealthy drug use in outpatient primary care and mental health settings, using a validated single question. This study analyzed VHA electronic health records data for patients who screened positive for unhealthy drug use (nâ=â570) and estimated logistic regression models to identify the predictors of receiving a recommendation for any follow-up and for specialty substance use disorder (SUD) treatment. Bivariate tests were used for other analyses. RESULTS: Among patients who screened positive for unhealthy drug use, 66% received no recommendation to return to primary care or another setting from the screening clinician. Further, among the 23% of patients who received a recommendation to visit specialty SUD treatment, only 25% completed the visit within 60 days. Six percent of all positive screens both received a referral to specialty SUD treatment and acted upon it. CONCLUSIONS: In the context of mandatory drug use screening using a single item, rates of clinician action and patient receipt of care appeared low. Improved follow-up will require health systems to provide more supports for clinicians and patients at each of the stages from positive screen to attending the follow-up appointment.
Assuntos
Encaminhamento e Consulta , Transtornos Relacionados ao Uso de Substâncias/diagnóstico , Transtornos Relacionados ao Uso de Substâncias/terapia , Veteranos , Adolescente , Adulto , Idoso , Idoso de 80 Anos ou mais , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Pacientes Ambulatoriais/estatística & dados numéricos , Transtornos Relacionados ao Uso de Substâncias/epidemiologia , Estados Unidos , Veteranos/estatística & dados numéricos , Serviços de Saúde para Veteranos Militares/estatística & dados numéricos , Adulto JovemRESUMO
Little is known about the rates and predictors of substance use treatment received in the Military Health System among Army soldiers diagnosed with a postdeployment substance use disorder (SUD). We used data from the Substance Use and Psychological Injury Combat study to determine the proportion of active duty (n = 338,708) and National Guard/Reserve (n = 178,801) enlisted soldiers returning from an Afghanistan/Iraq deployment in fiscal years 2008 to 2011 who had an SUD diagnosis in the first 150 days postdeployment. Among soldiers diagnosed with an SUD, we examined the rates and predictors of substance use treatment initiation and engagement according to the Healthcare Effectiveness Data and Information Set criteria. In the first 150 days postdeployment 3.3% of active duty soldiers and 1.0% of National Guard/Reserve soldiers were diagnosed with an SUD. Active duty soldiers were more likely to initiate and engage in substance use treatment than National Guard/Reserve soldiers, yet overall, engagement rates were low (25.0% and 15.7%, respectively). Soldiers were more likely to engage in treatment if they received their index diagnosis in a specialty behavioral health setting. Efforts to improve substance use treatment in the Military Health System should include initiatives to more accurately identify soldiers with undiagnosed SUD. Suggestions to improve substance use treatment engagement in the Military Health System will be discussed.
Assuntos
Serviços de Saúde Militar , Militares , Transtornos Relacionados ao Uso de Substâncias , Humanos , Iraque , Guerra do Iraque 2003-2011 , Transtornos Relacionados ao Uso de Substâncias/epidemiologia , Transtornos Relacionados ao Uso de Substâncias/terapia , Estados UnidosRESUMO
Data from a nationally representative sample of private health plans reveal that special lifetime limits on behavioral health care are rare (used by 16% of products). However, most plans have special annual limits on behavioral health utilization; for example, 90% limit outpatient mental health and 93% limit outpatient substance abuse treatment. As a result, enrollees in the average plan face substantial out-of-pocket costs for long-lasting treatment: a median of $2,710 for 50 mental health visits, or $2,400 for 50 substance abuse visits. Plans' access to new managed care tools has not led them to stop using benefit limits for cost containment purposes.
Assuntos
Cobertura do Seguro/organização & administração , Programas de Assistência Gerenciada/organização & administração , Serviços de Saúde Mental/organização & administração , Setor Privado/organização & administração , Transtornos Relacionados ao Uso de Substâncias/terapia , Financiamento Pessoal , Gastos em Saúde , Pesquisa sobre Serviços de Saúde , Humanos , Cobertura do Seguro/economia , Programas de Assistência Gerenciada/economia , Serviços de Saúde Mental/economia , Setor Privado/economia , Transtornos Relacionados ao Uso de Substâncias/economiaRESUMO
BACKGROUND: Preventive service use among older adults is suboptimal. Unhealthy drinking may constitute a risk factor for failure to receive these services. OBJECTIVES: To determine the relationship between unhealthy drinking and receipt of recommended preventive services among elderly Medicare beneficiaries, applying the framework of current alcohol consumption guidelines. DESIGN/METHODS: The data source is the nationally representative 2003 Medicare Current Beneficiary Survey. The sample included community-dwelling, fee-for-service Medicare beneficiaries 65 years and older (N = 10,523). Based on self-reported drinking, respondents were categorized as nondrinkers, within-guidelines drinkers, exceeding monthly but not daily limits, or heavy episodic drinkers. Using survey and claims data, influenza vaccination, pneumonia vaccination, glaucoma screening, and mammogram receipt were determined. Bivariate and logistic regression analyses were conducted. RESULTS: Overall, 70.3% received flu vaccination and 49% received glaucoma screening during the year, 66.8% received pneumonia vaccination, and 56.2% of women received a mammogram over 2 years. In logistic regression, heavy episodic drinking was associated with lower likelihood of service receipt compared to drinking within guidelines: flu vaccination (OR 0.75, CI 0.59-0.96), glaucoma screening (OR 0.74, CI 0.58-0.95), and pneumonia vaccination (OR 0.75, CI 0.59-0.96). Nondrinkers when compared with those reporting drinking within guidelines were less likely to receive a mammogram (OR 0.83, CI 0.69-1.00). CONCLUSIONS: Heavy episodic drinking is associated with lower likelihood of receiving several preventive services. Practitioners should be encouraged to screen all elders regarding alcohol intake and in addition to appropriate intervention, consider elders reporting heavy episodic drinking at higher risk for non-receipt of preventive services.
Assuntos
Alcoolismo/epidemiologia , Medicare , Aceitação pelo Paciente de Cuidados de Saúde/estatística & dados numéricos , Serviços Preventivos de Saúde/estatística & dados numéricos , Idoso , Idoso de 80 Anos ou mais , Estudos Transversais , Feminino , Glaucoma/diagnóstico , Humanos , Vacinas contra Influenza/uso terapêutico , Masculino , Razão de Chances , Vacinas Pneumocócicas/uso terapêutico , Estados Unidos/epidemiologiaRESUMO
Health plans have implemented cost sharing and administrative controls to constrain escalating prescription expenditures. These policies may impact physicians' prescribing and patients' use of these medications. Important clinical advances in the pharmacological treatment of addiction highlight the need to examine how pharmacy benefits consider medications for substance dependence. The extent of restrictions influencing the availability of these medications to consumers is unknown. We use nationally representative survey data to examine the extent and stringency of private health plans' management of naltrexone and disulfiram for alcohol dependence, and buprenorphine for opiate dependence. Thirty-one percent of insurance products excluded buprenorphine from formularies, whereas 55% placed it on the highest cost-sharing tier. Generic naltrexone is the only substance dependence medication that is both rarely excluded from formularies and usually placed on a lower cost-sharing tier. These findings demonstrate that pharmacy benefits have an impact on access to medications for substance abuse.
Assuntos
Acessibilidade aos Serviços de Saúde/estatística & dados numéricos , Cobertura do Seguro/estatística & dados numéricos , Seguro de Serviços Farmacêuticos/estatística & dados numéricos , Dissuasores de Álcool/economia , Dissuasores de Álcool/uso terapêutico , Alcoolismo/tratamento farmacológico , Buprenorfina/economia , Buprenorfina/uso terapêutico , Custo Compartilhado de Seguro , Coleta de Dados , Dissulfiram/economia , Dissulfiram/uso terapêutico , Medicamentos Genéricos/economia , Formulários Farmacêuticos como Assunto , Acessibilidade aos Serviços de Saúde/economia , Humanos , Cobertura do Seguro/economia , Seguro de Serviços Farmacêuticos/economia , Naltrexona/economia , Naltrexona/uso terapêutico , Antagonistas de Entorpecentes/economia , Antagonistas de Entorpecentes/uso terapêutico , Transtornos Relacionados ao Uso de Opioides/tratamento farmacológico , Estados UnidosRESUMO
OBJECTIVE: Improving depression treatment is critical given low rates of appropriate care. Health plan performance measures that address quality of antidepressant medication management, specifically, have been stagnating at relatively low levels. Identifying health plan characteristics associated with better performance could contribute to quality improvement for this aspect of depression treatment. METHODS: Data for 2003 were linked from two sources: a nationally representative survey of 368 health plans about their behavioral health services and the National Committee for Quality Assurance's Health Plan Employer Data and Information Set (HEDIS) antidepressant medication management (AMM) scores, which reflect the percentage of eligible members whose care met specified criteria. The analytic sample present in both data sets totaled 361 products offered by 183 plans. Plan characteristics were grouped into organizational, provider, and consumer domains. Bivariate tests and regression analyses were conducted to estimate the relationship between these characteristics and health plan performance on three AMM measures: effective acute-phase treatment, effective continuation-phase treatment, and optimal practitioner contact. RESULTS: Mean HEDIS AMM scores were 60% for effective acute-phase treatment, 43% for continuation-phase treatment, and 22% for optimal practitioner contact. Individual feedback to clinicians about their performance, lower cost sharing for outpatient mental health, and greater access to selective serotonin reuptake inhibitors were significantly associated with better plan performance in terms of antidepressant medication management. CONCLUSIONS: Health plan characteristics were significantly associated with the quality of one important aspect of depression care, antidepressant medication management. Many of the factors that were identified suggest actionable ways for plans to improve quality of depression care.
Assuntos
Antidepressivos/uso terapêutico , Relações Comunidade-Instituição , Transtorno Depressivo Maior/tratamento farmacológico , Transtorno Depressivo Maior/epidemiologia , Tratamento Farmacológico/estatística & dados numéricos , Fidelidade a Diretrizes , Serviços de Saúde Mental/normas , Cooperação do Paciente/estatística & dados numéricos , Tratamento Farmacológico/normas , Revisão de Uso de Medicamentos , Sistemas Pré-Pagos de Saúde/normas , Humanos , Indicadores de Qualidade em Assistência à Saúde , Inquéritos e Questionários , Estados UnidosRESUMO
We explored the techniques used by private health plans or by their contracted managed behavioral healthcare organizations (MBHOs) to maintain networks of behavioral health providers. In particular, we focused on differences by health plans' product types (health maintenance organization, point-of-service plan, or preferred provider organization) and contracting arrangements (MBHO contracts, comprehensive contracts, or no contracts). More than 94% of products selected providers using credentialing standards, particular specialists, or geographic coverage. To retain providers viewed as high quality, 54% offer reduced administrative burden and 44% higher fees. Only 16% reported steerage to a core group of highest-quality providers and few reported an annual bonus or guaranteed volume of referrals. Some standard activities are common, but some health plans are adopting other approaches to retain higher-quality providers.
Assuntos
Medicina do Comportamento/organização & administração , Credenciamento , Programas de Assistência Gerenciada/organização & administração , Serviços de Saúde Mental/organização & administração , Prática Privada/normas , Centros de Tratamento de Abuso de Substâncias/organização & administração , Medicina do Comportamento/normas , Área Programática de Saúde , Serviços Contratados/normas , Pesquisas sobre Atenção à Saúde , Sistemas Pré-Pagos de Saúde , Humanos , Programas de Assistência Gerenciada/classificação , Programas de Assistência Gerenciada/normas , Serviços de Saúde Mental/classificação , Serviços de Saúde Mental/normas , Legislação Referente à Liberdade de Escolha do Paciente , Organizações de Prestadores Preferenciais , Gestão da Qualidade Total , Estados UnidosRESUMO
BACKGROUND: Successful medication management for bipolar disorder requires clinicians to monitor and adjust regimens as needed, to achieve maximum effectiveness and patient adherence. This study aims to measure the prevalence of indications for medication adjustment at visits for bipolar disorder treatment; the frequency with which physicians recommend medication adjustments; and how strongly the indications predict the adjustments. METHODS: Data included 3,094 visits for 457 patients in Bipolar CHOICE, a comparative effectiveness study that compared treatment with lithium versus quetiapine. A set of indications for adjustment was matched to reports of whether the physician recommended a medication adjustment at that visit, and what type. Associations between indication and adjustment were examined using bivariate tests and hierarchical logistic mixed effects models. RESULTS: Medication adjustment was recommended at 63% of the visits where one of the indications was present, and at 53% of all visits. In multivariable analyses, adjustment was more likely to be recommended if there was an indication of non-response or side effects, for patients who started on quetiapine rather than lithium, or for patients who were female, married, employed or more educated. LIMITATIONS: The study's cross-sectional design implies that observed associations could result from confounding variables. Also, the CHOICE trial placed certain restrictions on physicians' medication choices, although this is not likely to have resulted in major alterations of prescribing patterns. CONCLUSIONS: Clinical inertia may help explain the lack of any adjustment recommendation at 37% of the visits where one of the indications was present. Other explanations could also apply, such as watchful waiting.