A mixed methods study of provider factors in buprenorphine treatment retention.

BACKGROUND: Low retention is a persistent challenge in the delivery of buprenorphine treatment for opioid use disorder (OUD). The goal of this study was to identify provider factors that could drive differences in treatment retention while accounting for the contribution of patient characteristics to retention. METHODS: We developed a novel a mixed-methods approach to explore provider factors that could drive retention while accounting for patient characteristics. We used Medicaid claims data from North Carolina in the United States to identify patient characteristics associated with higher retention. We then identified providers who achieved high and low retention rates. We matched high- and low-retention providers on their patients' characteristics. This matching created high- and low-retention provider groups whose patients had similar characteristics. We then interviewed providers while blinded to which belonged in the high- and low-retention groups on aspects of their practice that could affect retention rates, such as treatment criteria, treatment cost, and services offered. RESULTS: Less than half of patients achieved 180-day treatment retention with large differences by race and ethnicity. We did not find evidence that providers who achieved higher retention consistently did so by providing more comprehensive services or selecting for more stable patients. Rather, our findings suggest use of "high-threshold" clinical approaches, such as requiring participation in psychosocial services or strictly limiting dosages, explain differences in retention rates between providers whose patients have similar characteristics. All low-retention providers interviewed used a high-threshold practice compared to half of high-retention providers interviewed. Requiring patients to participate in psychosocial services, which were often paid out-of-pocket, appeared to be especially important in limiting retention. CONCLUSION: Providers who adopt low-threshold approaches to treatment may achiever higher retention rates than those who adopt high-threshold approaches. Addressing cost barriers and systemic racism are likely also necessary for improving buprenorphine treatment retention.

The Affordable Care Act : Against the Odds, It's Working.

This issue of the North Carolina Medical Journal focuses on the 10-year anniversary of the Patient Protection and Affordable Care Act (ACA), signed into law on March 23, 2010. Since its inception, the ACA has been highly controversial. Yet, it has contributed to positive improvements in our health care system. The ACA expanded health insurance coverage to more of the uninsured, made investments in prevention and in improving quality of care, and started our journey toward value-based care. This issue brief touches on how the law has been implemented in North Carolina, along with an assessment of the successes and failures of the law. It is followed by more detailed commentaries on specific aspects of the law and its implementation in our state. While much has been accomplished in the last 10 years, more is needed to achieve our goals of an affordable, equitable, and accessible health care system-one that promotes positive health outcomes while reducing unnecessary costs.

Primary Care Providers And Specialists Deliver Comparable Buprenorphine Treatment Quality.

In response to rising numbers of opioid overdose deaths, primary care providers have been called on to play a greater role in delivering buprenorphine treatment for opioid use disorder. However, policy makers and providers have raised concerns that expanding treatment access may reduce treatment quality and that primary care providers are not well equipped to deliver buprenorphine treatment. We investigated two research questions in response to these concerns: How did buprenorphine treatment use and quality change in North Carolina Medicaid from 2014 to 2017, and how did buprenorphine treatment quality differ between primary care providers and specialists in North Carolina Medicaid during this period? We measured buprenorphine treatment quality as patients' retention in treatment and providers' adherence to treatment guidelines. We found that the number of enrollees receiving medication treatment for opioid use disorder increased substantially, but the percentage of enrollees with the disorder receiving treatment remained low. The quality of buprenorphine treatment increased during the study period, and primary care providers provided care of comparable or higher quality compared with that of other providers. Treatment quality for buprenorphine treatment is improving, but there remains room for improvement in both use and quality. Our results support the role of primary care providers in expanding treatment for opioid use disorder.

Strategies for implementing best practices in independent physician associations.

OBJECTIVES: Scholars have highlighted the importance of preventing hospital admissions and readmissions for individuals with costly chronic conditions. Providing effective care management strategies can help reduce inpatient admissions, thereby reducing rising health care costs. However, implementing effective care management strategies may be more difficult for independent physician associations (IPAs) that contract with multiple organizations that have competing interests and agendas. This study aims to identify and investigate strategies that facilitate the implementation of evidence-based best practices among IPAs. STUDY DESIGN: The research synthesized peer-reviewed literature to identify best practices in chronic disease management for Medicare beneficiaries. Subsequently, 20 key informant interviews were conducted to explore barriers and facilitators in adapting these best practices in IPA settings. Informant interviews were conducted with 3 key groups: executives, medical directors, and care managers. METHODS: Key informant interviews were conducted to explore barriers and facilitators in implementing best care management practices. RESULTS: Key informants provided unique insights regarding the challenges of implementing best care management practices among IPAs. These challenges included implementing and sustaining the operations of evidence-based care management programs while maintaining contractual obligations to health plans, engaging physicians in large and diverse networks, and building high-touch programs in large geographic areas using risk-stratifying algorithms. CONCLUSIONS: IPA managed care organizations require unique considerations in regard to selected strategies used to manage chronic disease in Medicare populations. These considerations are critical for optimal management of the population, particularly in a risk-based or pay-for-performance environment.

The effect of Medicaid expansion on use of opioid agonist treatment and the role of provider capacity constraints.

OBJECTIVE: To determine the effect of Medicaid expansion on the use of opioid agonist treatment for opioid use disorder (OUD) and to examine heterogeneous effects by provider supply and Medicaid acceptance rates. DATA SOURCES: Yearly state-level data on methadone dispensed from opioid treatment programs (OTPs), buprenorphine dispensed from OTPs and pharmacies, number of OTPs and buprenorphine-waivered providers, and percent of OTPs and physicians accepting Medicaid. STUDY DESIGN: This study used difference-in-differences models to examine the effect of Medicaid expansion on the amount of methadone and buprenorphine dispensed in states between 2006 and 2017. Interaction terms were used to estimate heterogeneous effects. Sensitivity analyses included testing the association of outcomes with Medicaid enrollment and state insurance rates. PRINCIPAL FINDINGS: The estimated effects of Medicaid expansion on buprenorphine and methadone dispensed were positive but imprecise, meaning we could not rule out negative or null effects of expansion. The estimated associations between state insurance rates and dispensed methadone and buprenorphine were centered near zero, suggesting that improvements in health coverage may not have increased OUD treatment use. The effect of Medicaid expansion was larger in the states with the most waivered providers compared to states with the fewest waivered providers. In the states with the most waivered providers, the average estimated effect of expansion on buprenorphine dispensed was 12 kg/y, enough to treat about 7500 individuals. We did not find evidence that the effect of expansion was consistently modified by OTP concentration, OTP Medicaid acceptance, or physician Medicaid acceptance. CONCLUSIONS: Gains in health coverage may not be sufficient to increase OUD treatment, even in the context of high treatment need. Provider capacity likely limited Medicaid expansion's effect on buprenorphine dispensed. Policies to increase buprenorphine providers, such as ending the waiver requirement, may be needed to ensure coverage gains translate to treatment access.

Health Status and Access to Care for the North Carolina Medicaid Gap Population.

BACKGROUND North Carolina remains one of several states that has not expanded Medicaid eligibility criteria to cover all low-income adults, leading to the so-called Medicaid gap, a population ineligible for Medicaid and too poor for premium subsidies through the federal Health Insurance Marketplace. Our objective was to characterize the health care access and health status of the Medicaid gap population in North Carolina.METHODS We combined annual data from the Behavioral Risk Factor Surveillance Survey (2013-2016). Respondents who were uninsured and earning below 100% of the federal poverty guidelines (FPG) were classified as falling within the Medicaid gap and were compared to insured populations below FPG, representing the traditional Medicaid population, and to individuals above the FPG, regardless of insurance status. We reported health care access, receipt of preventive care, and current health status in unadjusted and demographically adjusted models.RESULTS Compared to either traditional Medicaid or above FPG groups, those in the Medicaid gap were 3 times as likely to have no regular source of care and twice as likely to report delaying needed care due to cost. Individuals in the Medicaid gap were more likely than individuals above FPG to report multiple chronic conditions (22% versus 16%) or a functional disability (35% versus 15%), but less likely than the traditional Medicaid population to do so.CONCLUSION While less likely than the traditional Medicaid population to have complex health needs, we found that individuals in the North Carolina Medicaid gap report numerous health care access barriers and lower use of preventive care.

Tailored Plans: The Next Step in a Long Evolution.

Medicaid transformation in North Carolina marks the next step in a lengthy history of caring for individuals with behavioral health challenges. "Tailored" health plans will cover people with severe mental illness, substance use disorders, intellectual/developmental disabilities, and traumatic brain injury, a vulnerable population that North Carolina's LME/MCOs are uniquely qualified to serve.

Utilization and Adherence in Medical Homes: An Assessment of Rural-Urban Differences for People With Severe Mental Illness.

BACKGROUND: The complex nature of managing care for people with severe mental illness (SMI), including major depression, bipolar disorder, and schizophrenia, is a challenge for primary care practices, especially in rural areas. The team-based emphasis of medical homes may act as an important facilitator to help reduce observed rural-urban differences in care. OBJECTIVE: The objective of this study was to examine whether enrollment in medical homes improved care in rural versus urban settings for people with SMI. RESEARCH DESIGN: Secondary data analysis of North Carolina Medicaid claims from 2004-2007, using propensity score weights and generalized estimating equations to assess differences between urban, nonmetropolitan urban and rural areas. SUBJECTS: Medicaid-enrolled adults with diagnoses of major depressive disorder, bipolar disorder or schizophrenia. Medicare/Medicaid dual eligibles were excluded. MEASURES: We examined utilization measures of primary care use, specialty mental health use, inpatient hospitalizations, and emergency department use and medication adherence. RESULTS: Rural medical home enrollees generally had higher primary care use and medication adherence than rural nonmedical home enrollees. Rural medical home enrollees had fewer primary care visits than urban medical home enrollees, but both groups were similar on the other outcome measures. These findings varied somewhat by SMI diagnosis. CONCLUSIONS: Findings indicate that enrollment in medical homes among rural Medicaid beneficiaries holds the promise of reducing rural-urban differences in care. Both urban and rural medical homes may benefit from targeted resources to help close the remaining gaps and to improve the success of the medical home model in addressing the health care needs of people with SMI.

Do Live Discharge Rates Increase as Hospices Approach Their Medicare Aggregate Payment Caps?

CONTEXT: The rate of live discharge from hospice and the proportion of hospices exceeding their aggregate caps have both increased for the last 15 years, becoming a source of federal scrutiny. The cap restricts aggregate payments hospices receive from Medicare during a 12-month period. The risk of repayment and the manner in which the cap is calculated may incentivize hospices coming close to their cap ceilings to discharge existing patients before the end of the cap year. OBJECTIVE: The objective of this work was to explore annual cap-risk trends and live discharge patterns. We hypothesized that as a hospice comes closer to exceeding its cap, a patient's likelihood of being discharged alive increases. METHODS: We analyzed monthly hospice outcomes using 2012-2013 Medicare claims. RESULTS: Adjusted analyses showed a positive and statistically significant relationship between cap risk and live discharges. CONCLUSION: Policymakers ought to consider the unintended consequences the aggregate cap may be having on patient outcomes of care.

Impact of Postdischarge Follow-Up Care on Medicare Expenditures: Does Rural Make a Difference?

Reducing postdischarge Medicare expenditures is a key focus for hospitals. Early follow-up care is an important piece of this focus, but it is unclear whether there are rural-urban differences in the impact of follow-up care on Medicare expenditures. To assess this difference, we use the Medicare Current Beneficiary Survey, Cost and Use Files, 2000-2010. We conduct a retrospective analysis of 30-day postdischarge Medicare expenditures using two-stage residual inclusion with a quantile regression, where the receipt of 7-day follow-up care was the main independent variable. Postdischarge follow-up care increased the 25th percentile of 30-day expenditures, decreased the 75th percentile, and there were no rural-urban differences. Partial effects show postdischarge follow-up care resulted in higher 30-day expenditures among low-cost rural beneficiaries. Ensuring early follow-up care for high-cost beneficiaries may be advantageous to both rural and urban providers in helping reduce postdischarge Medicare expenditures.

The effect of narrow network plans on out-of-pocket cost.

OBJECTIVES: To estimate the effects of selecting a narrow provider network on outpatient utilization and outpatient out-of-pocket (OOP) expenditures among individuals who chose to enroll in a narrow network plan in 2014. STUDY DESIGN: Claims data from a large insurer in the southeastern United States. METHODS: The sample consisted of individuals continuously enrolled for 2 years (2013-2014) who had Affordable Care Act-compliant plans in 2014. We compared unadjusted results and then used difference-in-differences (DID) models to determine the effect of narrow networks on the number of outpatient visits and outpatient OOP expenditures. RESULTS: Our DID model found no significant change in visits or outpatient OOP expenditures for individuals who selected a narrow network plan in 2014. However, unadjusted outpatient OOP expenditures and premiums were lower for individuals who selected narrow network plans. CONCLUSIONS: Our findings suggest that individuals who selected narrow network plans in 2014 were able to keep costs low without changing their overall number of outpatient visits. Narrow network plans can reduce costs to beneficiaries without affecting the volume of outpatient visits, if appropriate incentives to visit participating providers are followed.

A Positive Association Between Hospice Profit Margin And The Rate At Which Patients Are Discharged Before Death.

Hospice care is designed to support patients and families through the final phase of illness and death. Yet for more than a decade, hospices have steadily increased the rate at which they discharge patients before death-a practice known as "live discharge." Although certain live discharges are consistent with high-quality care, regulators have expressed concern that some hospices' desire to maximize profits drives them to inappropriately discharge patients. We used Medicare claims data for 2012-13 and cost reports for 2011-13 to explore relationships between hospice-level financial margins and live discharge rates among freestanding hospices. Adjusted analyses showed positive and significant associations between both operating and total margins and hospice-level rates of live discharge: One-unit increases in operating and total margin were associated with increases of 3 percent and 4 percent in expected hospice-level live discharge rates, respectively. These findings suggest that additional research is needed to explore links between profitability and patient-centeredness in the Medicare hospice program.

Plan Selection in the Non-Group Market in the First Year of the Health Insurance Marketplace.

BACKGROUND The Affordable Care Act (ACA)-created Marketplaces reduced barriers to entry in the non-group health insurance market. Although tax credits were available to individuals who enrolled in qualified health plans (QHPs) beginning in 2014, many individuals chose not to switch plans. We examined characteristics associated with switching from a non-ACA compliant plan to a QHP in 2014 and, conditional on switching, the characteristics associated with selection of a specific plan level.METHODS Using claims data from a large commercial insurer, we examined characteristics associated with switching to a QHP in 2014. For those who did switch, we used a multinomial logit model to estimate odds of selecting different metal levels-representing varying degrees of coverage-for a group of the highest and lowest risk individuals.RESULTS We found individuals most likely to benefit from the premium and benefit requirements on QHPs were more likely to switch to QHPs. Individuals at high-risk for high health care expenditures who had advance premium tax credits (APTCs) had lower odds of choosing a less generous plan compared to individuals without APTCs (odds of bronze plan over silver: 0.40, CI: 0.30 - 0.55), while individuals at low-risk of being high cost with APTCs were more likely to select a plan with a lower premium (odds bronze plan over silver: 1.35, CI: 1.09 - 1.66).LIMITATIONS This study was conducted with data from 1 health plan, limiting its national generalizability; however, this study is a good representation of activity within the state.CONCLUSIONS APTCs are important for ensuring that less healthy individuals are able to afford adequate levels of coverage.

Factors Driving Live Discharge From Hospice: Provider Perspectives.

CONTEXT: The proportion of patients disenrolling from hospice before death has increased over the decade with significant variations across hospice types and regions. Such trends have raised concerns about live disenrollment's effect on care quality. Live disenrollment may be driven by factors other than patient preference and may create discontinuities in care, disrupting ongoing patient-provider relationships. Researchers have not explored when and how providers make this decision with patients. OBJECTIVE: The objective of this study was to ascertain provider perspectives on key drivers of live discharge from the Medicare hospice program. METHODS: We conducted semistructured telephone interviews with 18 individuals representing 14 hospice providers across the country. Transcriptions were coded and analyzed using a template analysis approach. RESULTS: Analysis generated four themes: 1) difficulty estimating patient prognosis, 2) fear of Centers for Medicare & Medicaid Services audits, 3) rising market competition, and 4) challenges with inpatient contracting. Participants emphasized challenges underlying each decision to discharge patients alive, stressing that there often exists a gray line between appropriate and inappropriate discharges. Discussions also focused on scenarios in which financial motivations drive enrollment and disenrollment practices. CONCLUSION: This study provides significant contributions to existing knowledge about hospice enrollment and disenrollment patterns. Results suggest that live discharge patterns are often susceptible to market and regulatory forces, which may have contributed to the rising national rate.

Rural-Urban Differences in the Effect of Follow-Up Care on Postdischarge Outcomes.

OBJECTIVE: To assess rural-urban differences in quality of postdischarge care among Medicare beneficiaries, controlling for selection bias of postdischarge services. DATA SOURCES: The Medicare Current Beneficiary Survey (MCBS), Cost and Use Files from 2000 to 2010, the Area Resource File, Provider of Services File, and the Dartmouth Atlas of Health Care. STUDY DESIGN: Retrospective analysis of 30- and 60-day hospital readmission, emergency department (ED) use, and mortality using two-stage residual inclusion; receipt of 14-day follow-up care was the main independent variable. DATA EXTRACTION METHOD: We defined index admission from the MCBS as any admission without a previous admission within 60 days. PRINCIPAL FINDINGS: Noninstrumental variables estimation was the preferred estimation strategy. Fourteen-day follow-up care reduced the risk of readmission, ED use, and mortality. There were no rural- urban differences in the effect of 14-day follow-up care on readmission and mortality. Rural beneficiaries experienced a greater effect of 14-day follow-up care on reducing 30-day ED use compared to urban beneficiaries. CONCLUSIONS: Follow-up care reduces 30- and 60-day readmission, ED use, and mortality. Rural and urban Medicare beneficiaries experience similar beneficial effects of follow-up care on the outcomes. Policies that improve follow-up care in rural settings may be beneficial.

Rural Medicare Beneficiaries Have Fewer Follow-up Visits and Greater Emergency Department Use Postdischarge.

BACKGROUND: Hospitals are focused on improving postdischarge services for older adults, such as early follow-up care after hospitalization to reduce readmissions and unnecessary emergency department (ED) use. Rural Medicare beneficiaries face many barriers to receiving quality care, but little is known about their postdischarge care and outcomes. We hypothesize that rural Medicare beneficiaries compared with urban beneficiaries, will have fewer follow-up visits, and a greater likelihood of readmission and ED use. METHODS: We conducted a retrospective analysis of elderly Medicare beneficiaries discharged home using the Medicare Current Beneficiary Survey, Cost and Use files, 2000-2010. Multivariate Cox proportional hazard models were used to assess the risk of rural residency on readmission, ED use, and follow-up care up to 30 days' postdischarge. Covariates include demographic, health, and hospital-level characteristics. RESULTS: Compared with urban beneficiaries, Medicare beneficiaries living in isolated rural settings had a lower rate of follow-up care [hazard ratio (HR)=0.81, P<0.001]. Beneficiaries in large and small rural settings had a greater risk of an ED visit compared with urban beneficiaries (HR=1.44, P<0.001; HR=1.52, P<0.01). Rural beneficiaries did not have a greater risk of readmission, though risk of readmission was higher for beneficiaries discharged from hospitals in large and small rural settings (HR=1.33, P<0.05; HR=1.42, P<0.05). CONCLUSIONS: This study provides evidence of lower quality postdischarge care for Medicare beneficiaries in rural settings. As readmission penalties expand, hospitals serving rural beneficiaries may be disproportionately affected. This suggests a need for policies that increase follow-up care in rural settings.

Implementing the Affordable Care Act in North Carolina: the rubber hits the road.

The health insurance mandate, perhaps the best-known provision of the Patient Protection and Affordable Care Act of 2010 (ACA), is slated to go into effect on January 1, 2014. Yet most people do not know how the ACA will affect them. More than one-third of people in a recent national poll were unaware that new health insurance marketplaces will make it easier to purchase coverage or that some people will qualify for subsidies to help them purchase coverage. The ACA includes many other provisions that will have a profound impact on our health care delivery system. Some changes are already helping to break down silos in the delivery of care. Groups of health care professionals are working together to manage the health of populations. The ACA places a much greater emphasis on measuring quality and on paying health professionals and health care institutions based on the value of the services they provide. In addition, the ACA makes greater investments in prevention and in population health management. This issue brief highlights some of the health system changes that have taken place over the past 3 years, as well as some of the potential changes that are yet to come relating to insurance coverage, access to care, quality of care, rising health care costs, and overall population health.

Honoring their service: behavioral health services in North Carolina for military service members, veterans, and their families.

The North Carolina Institute of Medicine Task Force on Behavioral Health Services for the Military and Their Families examined the adequacy of Medicaid- and state-funded services for mental health conditions, developmental disabilities (including traumatic brain injury), and substance abuse that are currently available in North Carolina to military service members, veterans, and their families. The task force determined that there are several gaps in services and made 13 recommendations related to federal, state, and local community resources. This article reviews the work of the task force and current efforts to improve services in North Carolina.