Systematic Identification and Categorization of Opioid Prescribing and Dispensing Policies in 16 States and Washington, DC.

OBJECTIVES: State policies can impact opioid prescribing or dispensing. Some state opioid policies have been widely examined in empirical studies, including prescription drug monitoring programs and pain clinic licensure requirements. Other relevant policies might exist that have received limited attention. Our objective was to identify and categorize a wide range of state policies that could affect opioid prescribing/dispensing. METHODS: We used stratified random sampling to select 16 states and Washington, DC, for our sample. We collected state regulations and statutes effective during 2020 from each jurisdiction, using search terms related to opioids, pain management, and prescribing/dispensing. We then conducted qualitative template analysis of the data to identify and categorize policy categories. RESULTS: We identified three dimensions of opioid prescribing/dispensing laws: the prescribing/dispensing rule, its applicability, and its disciplinary consequences. Policy categories of prescribing/dispensing rules included clinic licensure, staff credentials, evaluating the appropriateness of opioids, limiting the initiation of opioids, preventing the diversion or misuse of opioids, and enhancing patient safety. Policy categories related to applicability of the law included the pain type, substance type, practitioner, setting, payer, and prescribing situation. The disciplinary consequences dimension included specific consequences and inspection processes. DISCUSSION: Policy categories within each dimension of opioid prescribing/dispensing laws could become a foundation for creating variables to support empirical analyses of policy effects, improving operationalization of policies in empirical studies, and helping to disentangle the effects of multiple state laws enacted at similar times to address the opioid crisis. Several of the policy categories we identified have been underexplored in previous empirical studies.

Urine drug testing in the context of opioid analgesic prescribing for chronic pain: a content analysis of U.S. state laws in 2022.

BACKGROUND: In response to the opioid crisis, U.S. states have passed laws requiring urine drug testing (UDT) when opioid analgesics are prescribed for chronic pain. We sought to identify state law UDT requirements. METHODS: We searched NexisUni legal database using terms related to UDT, chronic pain, and opioids. We included laws effective during spring 2022 that required UDT when opioids were prescribed for chronic pain. We performed deductive content analysis, coding laws for mandated UDT frequency, type of clinician and type of payer to whom the law applied, and circumstances under which UDT was mandated. RESULTS: We found 32 laws across 13 states that met our inclusion criteria. UDT requirements varied substantially by state, including with regard to the type of clinician to whom the law applied, the mandated frequency of UDT (eg, at initiation/assessment, at least annually, more than once per year), and the circumstances in which UDT was mandated (eg, patient had substance use disorder; dosage/day threshold). DISCUSSION: Relatively few states have UDT mandates associated with prescribing opioids as chronic pain treatment. When developing policy indicators for empirical studies, researchers evaluating how UDT policy affects health outcomes must consider the complexity and lack of uniformity of UDT requirements. In addition, even if states mandate UDT, it is unclear whether clinicians understand the best way to use the test results.

Evidence-Based Best Practices for Outpatient Management of Warfarin.

Many best practices have been described for organizing a clinic to manage warfarin. Although these practices may have face validity, they may not be based on empirical analysis. Here, we describe our decade-long effort to apply the Structure-Process-Outcome model of quality measurement as a basis for measuring and improving outpatient warfarin management in the Veterans Health Administration. The purpose of the article is to raise awareness of this body of work with pharmacists who could potentially incorporate the findings of this work into their own practice settings. We conclude with concrete suggestions for immediate implementation in clinical settings.

Using the Knowledge Base of Health Services Research to Redefine Health Care Systems.

This Perspective discusses 12 key facts derived from 50 years of health services research and argues that this knowledge base can stimulate innovative thinking about how to make health care systems safer, more efficient, more cost effective, and more patient centered, even as they respond to the needs of diverse communities.

America's Opioid Ecosystem: How Leveraging System Interactions Can Help Curb Addiction, Overdose, and Other Harms.

Opioids play an outsized role in America's drug problems, but they also play a critically important role in medicine. Thus, they deserve special attention. Illegally manufactured opioids (such as fentanyl) are involved in a majority of U.S. drug overdoses, but the problems are broader and deeper than drug fatalities. Depending on the drugs involved, there can be myriad physical and mental health consequences associated with having a substance use disorder. And it is not just those using drugs who suffer. Substance use and related behaviors can significantly affect individuals' families, friends, employers, and wider communities. Efforts to address problems related to opioids are insufficient and sometimes contradictory. Researchers provide a nuanced assessment of America's opioid ecosystem, highlighting how leveraging system interactions can reduce addiction, overdose, suffering, and other harms. At the core of the opioid ecosystem are the individuals who use opioids and their families. Researchers also include detail on ten major components of the opioid ecosystem: substance use disorder treatment, harm reduction, medical care, the criminal legal system, illegal supply and supply control, first responders, the child welfare system, income support and homeless services, employment, and education. The primary audience for this study is policymakers, but it should also be useful for foundations looking for opportunities to create change that have often been overlooked. This study can help researchers better consider the full consequences of policy changes and help members of the media identify the dynamics of interactions that deserve more attention.

Barriers to Price and Quality Transparency in Health Care Markets.

Consumers of health care in the United States often lack information on the actual prices of the care they receive and can also lack access to information about the quality of their care. RAND researchers gathered information on how health care prices are set, price variation in health care markets, barriers to price and quality transparency for consumers, and the extent to which price and quality information is used in marketing efforts. Public payers typically set prices for physicians and hospitals prospectively, and commercial health plans negotiate with physicians and hospitals to determine prices. Some research has shown substantial variation in negotiated prices, while other research suggests more moderate variation in some markets. Although the government does not directly affect prices paid by commercial health plans, commercial prices tend to be positively correlated with Medicare fee-for-service prices. Medicaid receives mandated rebates from drug manufacturers for dispensed prescriptions. Commercial health plans negotiate both the prices paid to pharmacies and any discounts and rebates received directly from drug manufacturers. Self-pay prices faced by consumers in pharmacies are set by individual pharmacies. The barriers to consumer price and quality transparency identified through this work generally represented limitations of existing tools. Consumer price transparency is being pursued by federal and state governments. Most commercial insurers have created price transparency tools to help members estimate the costs of various services. However, these tools can be difficult to navigate and do not always provide accurate pricing.

What Are the Determinants of Health System Performance? Findings from the Literature and a Technical Expert Panel.

BACKGROUND: The US health care system is the most expensive in the world, but it lags behind many other industrialized nations on multiple measures of effectiveness and quality. This poor performance may have played a role in the push to incentivize health care organizations to achieve high performance over a range of domains. Research is needed to understand the determinants of health system performance. METHODS: To identify key attributes of health systems associated with performance, a literature review was conducted. The characteristics identified were compiled into a Web-based rating instrument for use with a Technical Expert Panel composed of leaders in health systems and health services research. A modified Delphi process was initiated using three rounds to develop group consensus. RESULTS: The expert panel reached consensus on nine broad areas important to health system performance. Panelists also rated which specific attributes within those domains were predictive of performance. Panelists tended to rate the kind of characteristics used in past research (such as size, ownership, and profit status) as only somewhat or not at all important, while rating aspects of culture, leadership, and business execution as very important. CONCLUSION: There is limited empirical evidence and understanding of factors associated with health system performance. This study illustrates the value of using a modified Delphi process to bring experiential evidence to the task. These findings may help researchers refine their data collection efforts, policy makers craft better policies to incentivize high performance, and health leaders build better systems.

The importance of understanding and measuring health system structural, functional, and clinical integration.

OBJECTIVE: We explore if there are ways to characterize health systems-not already revealed by secondary data-that could provide new insights into differences in health system performance. We sought to collect rich qualitative data to reveal whether and to what extent health systems vary in important ways across dimensions of structural, functional, and clinical integration. DATA SOURCES: Interviews with 162 c-suite executives of 24 health systems in four states conducted through "virtual" site visits between 2017 and 2019. STUDY DESIGN: Exploratory study using thematic comparative analysis to describe factors that may lead to high performance. DATA COLLECTION: We used maximum variation sampling to achieve diversity in size and performance. We conducted, transcribed, coded, and analyzed in-depth, semi-structured interviews with system executives, covering such topics as market context, health system origin, organizational structure, governance features, and relationship of health system to affiliated hospitals and POs. PRINCIPAL FINDINGS: Health systems vary widely in size and ownership type, complexity of organization and governance arrangements, and ability to take on risk. Structural, functional, and clinical integration vary across systems, with considerable activity around centralizing business functions, aligning financial incentives with physicians, establishing enterprise-wide EHR, and moving toward single signatory contracting. Executives describe clinical integration as more difficult to achieve, but essential. Studies that treat "health system" as a binary variable may be inappropriately aggregating for analysis health systems of very different types, at different degrees of maturity, and at different stages of structural, functional, and clinical integration. As a result, a "signal" indicating performance may be distorted by the "noise." CONCLUSIONS: Developing ways to account for the complex structures of today's health systems can enhance future efforts to study systems as complex organizations, to assess their performance, and to better understand the effects of payment innovation, care redesign, and other reforms.

Are value-based incentives driving behavior change to improve value?

OBJECTIVES: To understand physician organization (PO) responses to financial incentives for quality and total cost of care among POs that were exposed to a statewide multipayer value-based payment (VBP) program, and to identify challenges that POs face in advancing the goals of VBP. STUDY DESIGN: Semistructured qualitative interviews and survey. METHODS: We drew a stratified random sample of 40 multispecialty California POs (25% of the POs that were eligible for incentives). In-person interviews were conducted with physician leaders and a survey was administered on actions being taken to reduce costs and redesign care and to discuss the challenges to improving value. We performed a thematic analysis of interview transcripts to identify common actions taken and challenges to reducing costs. RESULTS: VBP helps to promote care delivery transformation among POs, although efforts varied across organizations. Investments are occurring primarily in strategies to control hospital costs and redesign primary care, particularly for chronically ill patients; specialty care redesign is largely absent. Physician payment incentives for value remain small relative to total compensation, with continued emphasis on productivity. Challenges cited include the lack of a single enterprisewide electronic health records platform for information exchange, limited ability to influence specialists who were not exclusive to the organization, lack of payer cost and utilization data to manage costs, inability to recoup care redesign investments given the small size of VBP incentives, and lack of physician cost awareness. CONCLUSIONS: Transformation could be advanced by strengthening financial incentives for value; engaging specialists in care redesign and delivering value; enhancing partnerships among POs, hospitals, and payers to align quality and cost actions; strengthening information exchange across providers; and applying other strategies to influence physician behavior.

Understanding U.S. Health Systems: Using Mixed Methods to Unpack Organizational Complexity.

INTRODUCTION: As hospitals and physician organizations increasingly vertically integrate, there is an important opportunity to use health systems to improve performance. Prior research has largely relied on secondary data sources, but little is known about how health systems are organized "on the ground" and what mechanisms are available to influence physician practice at the front line of care. METHODS: We collected in-depth information on eight health systems through key informant interviews, descriptive surveys, and document review. Qualitative data were systematically coded. We conducted analyses to identify organizational structures and mechanisms through which health systems influence practice. RESULTS: As expected, we found that health systems vary on multiple dimensions related to organizational structure (e.g., size, complexity) which reflects history, market and mission. With regard to levers of influence, we observed within-system variation both in mechanisms (e.g., employment of physicians, system-wide EHR, standardization of service lines) and level of influence. Concepts such as "core" versus "peripheral" were more salient than "ownership" versus "contract." DISCUSSION: Data from secondary sources can help identify and map health systems, but they do not adequately describe them or the variation that exists within and across systems. To examine the degree to which health systems can influence performance, more detailed and nuanced information on health system characteristics is necessary. CONCLUSION: The mixed-methods data accrual approach used in this study provides granular qualitative data that enables researchers to describe multi-layered health systems, grasp the context in which they operate, and identify the key drivers of performance.

Resources and Capabilities of the Department of Veterans Affairs to Provide Timely and Accessible Care to Veterans.

The Veterans Access, Choice, and Accountability Act of 2014 addressed the need for access to timely, high-quality health care for veterans. Section 201 of the legislation called for an independent assessment of various aspects of veterans' health care. The RAND Corporation was tasked with an assessment of the Department of Veterans Affairs (VA) current and projected health care capabilities and resources. An examination of data from a variety of sources, along with a survey of VA medical facility leaders, revealed the breadth and depth of VA resources and capabilities: fiscal resources, workforce and human resources, physical infrastructure, interorganizational relationships, and information resources. The assessment identified barriers to the effective use of these resources and capabilities. Analysis of data on access to VA care and the quality of that care showed that almost all veterans live within 40 miles of a VA health facility, but fewer have access to VA specialty care. Veterans usually receive care within 14 days of their desired appointment date, but wait times vary considerably across VA facilities. VA has long played a national leadership role in measuring the quality of health care. The assessment showed that VA health care quality was as good or better on most measures compared with other health systems, but quality performance lagged at some VA facilities. VA will require more resources and capabilities to meet a projected increase in veterans' demand for VA care over the next five years. Options for increasing capacity include accelerated hiring, full nurse practice authority, and expanded use of telehealth.

What cognitive science tells us about the design of reports for consumers.

The health services literature many articles related to expanding and refining quality measures. But the rich body of empirical research on how people process information has rarely been applied to the challenge of presenting complex information about health care in ways that facilitate its comprehension and use. In this article, the authors review key findings from this research. Based on their review, the authors develop some general principles for presenting information and demonstrate their utility by assessing three Web sites that report performance data.

Reporting about health care quality: a guide to the galaxy.

A review of research on the reporting of health care quality information and related fields in applied social and cognitive science led to identification of seven basic principles that should be followed when planning to report health care quality information to consumers or other audiences: (a) know the audience: who they are, what they care about, and what actions they can take; (b) identify constraints that limit what is feasible; (c) consider barriers and facilitators to achieving objectives; (d) identify specific behaviors to target for change, and prioritize objectives; (e) design a report that specifically incorporates priorities and reflects trade-offs; (f) develop a plan for promotion and dissemination from the beginning; and (g) build in ongoing testing and evaluation to identify successes and areas needing improvement. Case studies provide many examples of unsuccessful reporting efforts that might have succeeded had these guiding principles been followed.

Small Ideas for Saving Big Health Care Dollars.

A focused review of recent RAND Health research identified small ideas that could save the U.S. health care system $13 to $22 billion per year, in the aggregate, if successfully implemented. In the substituting lower-cost treatments category, ideas are to reduce use of anesthesia providers in routine gastroenterology procedures for low-risk patients, change payment policy for emergency transport, increase use of lower-cost antibiotics for treatment of acute otitis media, shift care from emergency departments to retail clinics when appropriate, eliminate co-payments for higher-risk patients taking cholesterol-lowering drugs, increase use of $4 generic drugs, and reduce Medicare Part D use of brand-name prescription drugs by patients with diabetes. In the patient safety category, ideas are to prevent three types of health care-associated infections: (1) central line-associated bloodstream infections, (2) ventilator-associated pneumonia, and (3) catheter-associated urinary tract infections; use preoperative and anesthesia checklists to prevent operative and postoperative events; prevent in-facility pressure ulcers; use ultrasound guidance for central line placement; and prevent recurrent falls. Small ideas do not require systemic change; thus, they may be both more feasible to operationalize and less likely to encounter stiff political and organizational resistance.

Redirecting Innovation in U.S. Health Care: Options to Decrease Spending and Increase Value.

New medical technologies are a leading driver of U.S. health care spending. This article identifies promising policy options to change which medical technologies are created, with two related policy goals: (1) Reduce total health care spending with the smallest possible loss of health benefits, and (2) ensure that new medical products that increase spending are accompanied by health benefits that are worth the spending increases. The analysis synthesized information from peer-reviewed and other literature, a panel of technical advisors convened for the project, and 50 one-on-one expert interviews. The authors also conducted case studies of eight medical products. The following features of the U.S. health care environment tend to increase spending without also conferring major health benefits: lack of basic scientific knowledge about some disease processes, costs and risks of U.S. Food and Drug Administration (FDA) approval, limited rewards for medical products that could lower spending, treatment creep, and the medical arms race. The authors identified ten policy options that would help advance the two policy goals. Five would do so by reducing the costs and/or risks of invention and obtaining FDA approval: (1) Enable more creativity in funding basic science, (2) offer prizes for inventions, (3) buy out patents, (4) establish a public-interest investment fund, and (5) expedite FDA reviews and approvals. The other five options would do so by increasing market rewards for products: (1) Reform Medicare payment policies, (2) reform Medicare coverage policies, (3) coordinate FDA approval and Centers for Medicare & Medicaid Services coverage processes, (4) increase demand for technologies that decrease spending, and (5) produce more and more-timely technology assessments.

The Teen Photovoice Project: a pilot study to promote health through advocacy.

BACKGROUND: Clinicians, public health practitioners, and policymakers would like to understand how youth perceive health issues and how they can become advocates for health promotion in their communities. Traditional research methods can be used to capture these perceptions, but are limited in their ability to activate (excite and engage) youth to participate in health promotion activities. OBJECTIVES: To pilot the use of an adapted version of photovoice as a starting point to engage youth in identifying influences on their health behaviors in a process that encourages the development of health advocacy projects. METHODS: Application of qualitative and quantitative methods to a participatory research project that teaches youth the photovoice method to identify and address health promotion issues relevant to their lives. Participants included 13 students serving on a Youth Advisory Board (YAB) of the UCLA/RAND Center for Adolescent Health Promotion working in four small groups of two to five participants. Students were from the Los Angeles, California, metropolitan area. RESULTS: Results were derived from photograph sorting activities, analysis of photograph narratives, and development of advocacy projects. Youth frequently discussed a variety of topics reflected in their pictures that included unhealthy food choices, inducers of stress, friends, emotions, environment, health, and positive aspects of family. The advocacy projects used social marketing strategies, focusing on unhealthy dietary practices and inducers of stress. The youths' focus on obesity-related issues have contributed to the center's success in partnering with the Los Angeles Unified School District on a new community-based participatory research (CBPR) project. CONCLUSION: Youth can engage in a process of identifying community-level health influences, leading to health promotion through advocacy. Participants focused their advocacy work on selected issues addressing the types of unhealthy food available in their communities and stress. This process appears to provide meaningful insight into the youths' perspective on what influences their health behaviors.

Improving childhood asthma outcomes in the United States: a blueprint for policy action.

BACKGROUND/OBJECTIVE: Asthma is increasingly being recognized as an important public health concern for children in the United States. Effective management of childhood asthma may require not only improving guideline-based therapeutic interventions, but also addressing social and physical environmental risk factors. The objective of this project was to create a blueprint for improvement of national policy in this area. DESIGN/METHODS: A nominal group process with nationally recognized experts and leaders (referred to as "the committee") in childhood asthma. RESULTS: The committee identified 11 policy recommendations (numbered in order below) in 2 broad categories: Improving Health Care Delivery and Financing, and Strengthening the Public Health Infrastructure. Recommendations regarding Improving Health Care Delivery and Financing include the development and implementation of quality-of-care standards in 1) primary care, 2) self-management education, and 3) case-management interventions, and the expansion of insurance coverage and benefit design by 4) extending continuous health insurance coverage for all children, 5) developing model insurance benefits packages for essential childhood asthma services, and 6) educating health care purchasers in how to use them. Recommendations for Strengthening the Public Health Infrastructure include public funding of asthma services that fall outside the insurance system through establishing 7) public health grants to foster asthma-friendly communities and 8) school-based asthma initiatives. 9) Launching a national asthma public education campaign, 10) developing a national asthma surveillance system, and 11) establishing a national agenda for asthma prevention research, with an emphasis on epidemiologic and behavioral sciences, are also recommended. CONCLUSIONS: Implementing these recommendations will require coordination of activities at the national, state, and local community level, and within and outside the health care delivery system. With a further commitment of national and local resources, implementation of these recommendations will likely lead to improved child and family asthma outcomes in the United States. childhood asthma, health care policy, health care services.