High-density lipoprotein (HDL) as an indicator for alcohol use in a psychiatrically ill population.

AIMS: To examine the cross sectional and longitudinal associations between the Alcohol Use Disorders Identification Test-Concise (AUDIT-C) and differences in high-density lipoprotein (HDL) in a psychiatrically ill population. METHODS: Retrospective observational study using electronic health record data from a large healthcare system, of patients hospitalized for a mental health/substance use disorder (MH/SUD) from 1 July 2016 to 31 May 2023, who had a proximal AUDIT-C and HDL (N = 15 915) and the subset who had a repeat AUDIT-C and HDL 1 year later (N = 2915). Linear regression models examined the association between cross-sectional and longitudinal AUDIT-C scores and HDL, adjusting for demographic and clinical characteristics that affect HDL. RESULTS: Compared with AUDIT-C score = 0, HDL was higher among patients with greater AUDIT-C severity (e.g. moderate AUDIT-C score = 8.70[7.65, 9.75] mg/dl; severe AUDIT-C score = 13.02 [12.13, 13.90] mg/dL[95% confidence interval (CI)] mg/dl). The associations between cross-sectional HDL and AUDIT-C scores were similar with and without adjusting for patient demographic and clinical characteristics. HDL levels increased for patients with mild alcohol use at baseline and moderate or severe alcohol use at follow-up (15.06[2.77, 27.69] and 19.58[2.77, 36.39] mg/dL[95%CI] increase for moderate and severe, respectively). CONCLUSIONS: HDL levels correlate with AUDIT-C scores among patients with MH/SUD. Longitudinally, there were some (but not consistent) increases in HDL associated with increases in AUDIT-C. The increases were within range of typical year-to-year variation in HDL across the population independent of alcohol use, limiting the ability to use HDL as a longitudinal clinical indicator for alcohol use in routine care.

Racial and Ethnic Differences in Telemedicine Use.

Importance: Individuals of racial and ethnic minority groups may be less likely to use telemedicine in part due to lack of access to technology (ie, digital divide). To date, some studies have found less telemedicine use by individuals of racial and ethnic minority groups compared with White individuals, and others have found the opposite. What explains these different findings is unclear. Objective: To quantify racial and ethnic differences in the receipt of telemedicine and total visits with and without accounting for demographic and clinical characteristics and geography. Design, Setting, and Participants: This cross-sectional study included individuals who were continuously enrolled in traditional Medicare from March 2020 to February 2022 or until death. Exposure: Race and ethnicity, which was categorized as Black non-Hispanic, Hispanic, White non-Hispanic, other (defined as American Indian/Pacific Islander, Alaska Native, and Asian), and unknown/missing. Main Outcomes and Measures: Total telemedicine visits (audio-video or audio); total visits (telemedicine or in-person) per individual during the study period. Multivariable models were used that sequentially adjusted for demographic and clinical characteristics and geographic area to examine their association with differences in telemedicine and total visit utilization by documented race and ethnicity. Results: In this national sample of 14 305 819 individuals, 7.4% reported that they were Black, 5.6% Hispanic, and 4.2% other race. In unadjusted results, compared with White individuals, Black individuals, Hispanic individuals, and individuals of other racial groups had 16.7 (95% CI, 16.1-17.3), 32.9 (95% CI, 32.3-33.6), and 20.9 (95% CI, 20.2-21.7) more telemedicine visits per 100 beneficiaries, respectively. After adjustment for clinical and demographic characteristics and geography, compared with White individuals, Black individuals, Hispanic individuals, and individuals of other racial groups had 7.9 (95% CI, -8.5 to -7.3), 13.2 (95% CI, -13.9 to -12.6), and 9.2 (95% CI, -10.0 to -8.5) fewer telemedicine visits per 100 beneficiaries, respectively. In unadjusted and fully adjusted models, and in 2019 and the second year of the COVID-19 pandemic, Black individuals, Hispanic individuals, and individuals of other racial groups continued to have fewer total visits than White individuals. Conclusions and Relevance: The results of this cross-sectional study of US Medicare enrollees suggest that although nationally, Black individuals, Hispanic individuals, and individuals of other racial groups received more telemedicine visits during the pandemic and disproportionately lived in geographic regions with higher telemedicine use, after controlling for geographic region, Black individuals, Hispanic individuals, and individuals of other racial groups received fewer telemedicine visits than White individuals.

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

BACKGROUND: The rise in prevalence of high deductible health plans (HDHPs) in the United States may raise concerns for high-need, high-utilization populations such as those with comorbid chronic conditions. In this study, we examine changes in total and out-of-pocket (OOP) spending attributable to HDHPs for enrollees with comorbid substance use disorder (SUD) and cardiovascular disease (CVD). METHODS: We used de-identified administrative claims data from 2007 to 2017. SUD and CVD were defined using algorithms of ICD 9 and 10 codes and HEDIS guidelines. The main outcome measures of interest were spending measure for all non-SUD/CVD-related services, SUD-specific services, and CVD-specific services, for all services and medications specifically. We assessed both total and OOP spending. We used an intent-to-treat two-part model approach to model spending and computed the marginal effect of HDHP offer as both the dollar change and percent change in spending attributable to HDHP offer. RESULTS: Our sample included 33,684 enrollee-years and was predominantly white and male with a mean age of 53 years. The sample had high demonstrated substantial healthcare utilization with 94% using any non-SUD/CVD services, and 84% and 78% using SUD and CVD services, respectively. HDHP offer was associated with a 17.0% (95% CI = [0.07, 0.27] increase in OOP spending for all non-SUD/CVD services, a 21.1% (95% CI = [0.11, 0.31]) increase in OOP spending for all SUD-specific services, and a 13.1% (95% CI = [0.04, 0.23]) increase in OOP spending for all CVD-specific services. HDHP offer was also associated with a significant increase in OOP spending on non-SUD/CVD-specific medications and SUD-specific medications, but not CVD-specific medications. CONCLUSIONS: This study suggests that while HDHPs do not change overall levels of annual spending among enrollees with comorbid CVD and SUD, they may increase the financial burden of healthcare services by raising OOP costs, which could negatively impact this high-need and high-utilization population.

Use of Telemedicine and Quality of Care Among Medicare Enrollees With Serious Mental Illness.

Importance: During the COVID-19 pandemic, a large fraction of mental health care was provided via telemedicine. The implications of this shift in care for use of mental health service and quality of care have not been characterized. Objective: To compare changes in care patterns and quality during the first year of the pandemic among Medicare beneficiaries with serious mental illness (schizophrenia or bipolar I disorder) cared for at practices with higher vs lower telemedicine use. Design, Setting, and Participants: In this cohort study, Medicare fee-for-service beneficiaries with schizophrenia or bipolar I disorder were attributed to specialty mental health practices that delivered the majority of their mental health care in 2019. Practices were categorized into 3 groups based on the proportion of telemental health visits provided during the first year of the pandemic (March 2020-February 2021): lowest use (0%-49%), middle use (50%-89%), or highest use (90%-100%). Across the 3 groups of practices, differential changes in patient outcomes were calculated from the year before the pandemic started to the year after. These changes were also compared with differential changes from a 2-year prepandemic period. Analyses were conducted in November 2022. Exposure: Practice-level use of telemedicine during the first year of the COVID-19 pandemic. Main Outcomes and Measures: The primary outcome was the total number of mental health visits (telemedicine plus in-person) per person. Secondary outcomes included the number of acute hospital and emergency department encounters, all-cause mortality, and quality outcomes, including adherence to antipsychotic and mood-stabilizing medications (as measured by the number of months of medication fills) and 7- and 30-day outpatient follow-up rates after discharge for a mental health hospitalization. Results: The pandemic cohort included 120 050 Medicare beneficiaries (mean [SD] age, 56.5 [14.5] years; 66 638 females [55.5%]) with serious mental illness. Compared with prepandemic changes and relative to patients receiving care at practices with the lowest telemedicine use: patients receiving care at practices in the middle and highest telemedicine use groups had 1.11 (95% CI, 0.45-1.76) and 1.94 (95% CI, 1.28-2.59) more mental health visits per patient per year (or 7.5% [95% CI, 3.0%-11.9%] and 13.0% [95% CI, 8.6%-17.4%] more mental health visits per year, respectively). Among patients of practices with middle and highest telemedicine use, changes in adherence to antipsychotic and mood-stabilizing medications were -0.4% (95% CI, -1.3% to 0.5%) and -0.1% (95% CI, -1.0% to 0.8%), and hospital and emergency department use for any reason changed by 2.4% (95% CI, -1.5% to 6.2%) and 2.8% (95% CI, -1.2% to 6.8%), respectively. There were no significant differential changes in postdischarge follow-up or mortality rates according to the level of telemedicine use. Conclusions and Relevance: In this cohort study of Medicare beneficiaries with serious mental illness, patients receiving care from practices that had a higher level of telemedicine use during the COVID-19 pandemic had more mental health visits per year compared with prepandemic levels, with no differential changes in other observed quality metrics over the same period.

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

INTRODUCTION: High-deductible health plans (HDHPs) expose enrollees to increased out-of-pocket costs for their medical care, which can exacerbate the undertreatment of substance use disorders (SUDs). However, the factors that influence whether an enrollee with SUD chooses an HDHP are not well understood. In this study, we examine the factors associated with an individual with an SUD's decision to enroll in an HDHP. METHODS: Using de-identified administrative commercial claims and enrollment data from OptumLabs (2007-2017), we identified individuals at employers offering at least one HDHP and one non-HDHP plan. We modeled whether an enrollee chose an HDHP using linear regression on plan and enrollee demographic characteristics. Key plan characteristics included whether a plan had a health savings account (HSA) or a health reimbursement arrangement (HRA). Key demographic variables included age, race/ethnicity, census block income range, census block highest educational attainment, and sex. We separately investigate new enrollment decisions (i.e., not previously enrolled in an HDHP) and re-enrollment decisions, as well as decisions among single enrollees and families of differing sizes. The study also adjusted models for additional plan characteristics, employer and year fixed effects, and census division. Robust standard errors were clustered at the employer level. RESULTS: The sample comprised 30,832 plans and 318,334 enrollees. Among enrollees with new enrollment decisions, 24.6 % chose an HDHP; 93.8 % of HDHP enrollees chose to re-enroll in an HDHP. The study found the presence of a plan HRA to be associated with a higher probability of new and re-enrollment in an HDHP. We found that older enrollees with SUD were less likely to newly enroll in an HDHP, while enrollees who were non-White, living in lower-income census blocks, and living in lower educational attainment census blocks were more likely to newly enroll in an HDHP. Higher levels of health care utilization in the prior year were associated with a lower probability of newly enrolling in an HDHP but associated with a higher probability of re-enrolling. CONCLUSION: Given the emerging evidence that HDHPs may discourage SUD treatment, greater HDHP enrollment could exacerbate health disparities.

Prescribing Medications for Alcohol Use Disorder: A Qualitative Study of Primary Care Physician Decision Making.

PURPOSE: Over 29 million Americans have alcohol use disorder (AUD). Though there are effective medications for AUD (MAUD) that can be prescribed within primary care, they are underutilized. We aimed to explore how primary care physicians familiar with MAUD make prescribing decisions and to identify reasons for underuse of MAUD within primary care. METHODS: We conducted semistructured interviews with 19 primary care physicians recruited from a large online database of medical professionals. Physicians had to have started a patient on MAUD within the last 6 months in an outpatient setting. Inductive and deductive thematic analysis was informed by the theory of planned behavior. RESULTS: Physicians endorsed that it is challenging to prescribe MAUD due to several reasons, including: (1) somewhat negative personal beliefs about medication effectiveness and likelihood of patient adherence; (2) competing demands in primary care that make MAUD a lower priority; and, (3) few positive subjective norms around prescribing. To make MAUD prescribing a smaller component of their practice, physicians reported applying various rules of thumb to select patients for MAUD. These included recommending MAUD to the patients who seemed the most motivated to reduce drinking, those with the most severe AUD, and those who were also receiving other treatments for AUD. CONCLUSIONS: There is a challenging implementation context for MAUD due to competing demands within primary care. Future research should explore which strategies for identifying a subset of patients for MAUD are the most appropriate and most likely to improve population health and health equity.

High-deductible Health Plans and Nonfatal Opioid Overdose.

OBJECTIVES: Opioid-related overdose is a public health emergency in the United States. Meanwhile, high-deductible health plans (HDHPs) have become more prevalent in the United States over the last 2 decades, raising concern about their potential for discouraging high-need populations, like those with opioid use disorder (OUD), from engaging in care that may mitigate the probability of overdose. This study assesses the impact of an employer offering an HDHP on nonfatal opioid overdose among commercially insured individuals with OUD in the United States. RESEARCH DESIGN: We used deidentified insurance claims data from 2007 to 2017 with 97,788 person-years. We used an intent-to-treat, difference-in-differences regression framework to estimate the change in the probability of a nonfatal opioid overdose among enrollees with OUD whose employers began offering an HDHP insurance option during the study period compared with the change among those whose employer never offered an HDHP. We also used an event-study model to account for dynamic time-varying treatment effects. RESULTS: Across both comparison and treatment groups, 2% of the sample experienced a nonfatal opioid overdose during the study period. Our primary model and robustness checks revealed no impact of HDHP offer on the probability of a nonfatal overdose. CONCLUSIONS: Our study suggests that HDHP offer was not associated with an observed increase in the probability of nonfatal opioid overdose among commercially insured person-years with OUD. However, given the strong evidence that medications for OUD (MOUD) can reduce the risk of overdose, research should explore which facets of insurance design may impact MOUD use.

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

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

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

INTRODUCTION: Chronic pain affects an estimated 20% of U.S. adults. Because high-deductible health plans have captured a growing share of the commercial insurance market, it is unknown how high-deductible health plans impact care for chronic pain. METHODS: Using 2007-2017 claims data from a large national commercial insurer, statistical analyses conducted in 2022-2023 estimated changes in enrollee outcomes before and after their firm began offering a high-deductible health plan compared with changes in outcomes in a comparison group of enrollees at firms never offering a high-deductible health plan. The sample included 757,530 commercially insured adults aged 18-64 years with headache, low back pain, arthritis, neuropathic pain, or fibromyalgia. Outcomes, measured at the enrollee year level, included the probability of receiving any chronic pain treatment, nonpharmacologic pain treatment, and opioid and nonopioid prescriptions; the number of nonpharmacologic pain treatment days; number and days' supply of opioid and nonopioid prescriptions; and total annual spending and out-of-pocket spending. RESULTS: High-deductible health plan offer was associated with a 1.2 percentage point reduction (95% CI= -1.8, -0.5) in the probability of any chronic pain treatment and an $11 increase (95% CI=$6, $15) in annual out-of-pocket spending on chronic pain treatments among those with any use, representing a 16% increase in average annual out-of-pocket spending over the pre-high deductible health plan offer annual average. Results were driven by changes in nonpharmacologic treatment use. CONCLUSIONS: By reducing the use of nonpharmacologic chronic pain treatments and marginally increasing out-of-pocket costs among those using these services, high-deductible health plans may discourage more holistic, integrated approaches to caring for patients with chronic pain conditions.

Many Clinicians Implement Digital Equity Strategies To Treat Opioid Use Disorder.

Drawing upon a longitudinal survey of clinicians who treat patients with opioid use disorder (OUD), we report changes over time in telemedicine use, clinicians' attitudes, and digital equity strategies. Clinicians reported less use of telemedicine (both video and audio-only) in 2022 than in 2020. In March 2022, 77.0 percent of clinician respondents reported implementing digital equity strategies to help patients overcome barriers to video visits.

Telemedicine Use and Quality of Opioid Use Disorder Treatment in the US During the COVID-19 Pandemic.

Importance: Little is known about the potential implications of the rapid transition to telehealth during the COVID-19 pandemic for treatment of opioid use disorder (OUD). Objective: To examine the association between telemedicine adoption during the COVID-19 pandemic and indicators of OUD treatment quality. Design, Setting, and Participants: This cohort study analyzed deidentified administrative claims data from OptumLabs Data Warehouse. Claims for telemedicine visits were included for both the prepandemic period (March 14, 2019, to March 13, 2020) and pandemic period (March 14, 2020, to March 13, 2021). Patients with OUD and continuous enrollment in either commercial insurance or Medicare Advantage plans were included. Clinicians who provided office-based OUD care were included and categorized into low, medium, or high telemedicine use groups. Patients were attributed to the clinician (and corresponding telemedicine use group) from whom they received a plurality of OUD visits. Main Outcomes and Measures: The 4 outcomes were all outpatient visits, OUD visits (in person vs telemedicine) within 90 days of an index visit, medications for OUD (MOUD) prescribing, and OUD-related clinical events (including drug overdose, inpatient detoxification and rehabilitation center stay, or injection drug use-related infections). Results: The analysis included 11 801 patients (mean [SD] age, 53.9 [15.7] years; 5902 males [50.0%]) who were treated by 1768 clinicians. Clinicians with low vs high telemedicine use conducted a mean (SD) of 2.1% (2.5%) vs 69.5% (18.6%) of their office visits virtually in the pandemic period. While telemedicine use for OUD increased significantly from the prepandemic to pandemic periods, total OUD visit volume (in person plus telemedicine) per patient episode remained stable among both high (2.6 to 2.7 visits per patient episode) and low (3.1 to 3.3 visits per patient episode) telemedicine use groups. In adjusted analyses comparing the prepandemic with pandemic periods, there was no differential change in MOUD initiation (adjusted odds ratio [OR], 1.00; 95% CI, 0.84-1.19), MOUD days' supply (differential change in days' supply, -0.27; 95% CI, -1.84 to 1.30), or OUD-related clinical events (adjusted OR, 1.01; 95% CI, 0.73-1.24) among patients who were treated by clinicians in low vs high telemedicine use groups. Conclusions and Relevance: Results of this study revealed that clinical outcomes were similar among patients who were treated by clinicians with high and low telemedicine use during the COVID-19 pandemic, suggesting that telemedicine is a comparable alternative to in-person OUD care. There was no evidence that telemedicine was associated with increased access to or improved quality of OUD treatment.

Telemental health for clinical assessment and treatment.

Telemental health-the use of videoconferencing or audio only (telephone) in mental health care-has accelerated tremendously since the start of the covid-19 pandemic. Meta-analyses have examined the reliability (ie, concordance) of assessment and the efficacy/effectiveness of telemental health compared with in-person care. Results indicate that telemental health assessment and clinical outcomes are similar compared with in-person care but there is much unexplained variability, as well as evidence that patient clinical and demographic characteristics can influence these findings. Further, gaps exist in the literature regarding specific patient populations (eg, psychotic disorders, children/adolescents), treatment modalities (eg, group therapy), audio only telemedicine, and hybrid care that mixes in-person with telemental health care. These gaps provide important directions for the next generation of telemental health research. Comprehensive clinical guidelines from mental health organizations are available to telemental health practitioners and focus on five content themes: legal and regulatory issues, clinical considerations, standard operating procedures and protocols, technical requirements, and considerations of specific populations and settings.

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

BACKGROUND: The United States faces an ongoing drug crisis, worsened by the undertreatment of substance use disorders (SUDs). Family enrollment in high deductible health plans (HDHPs) and the resulting increased cost exposure could exacerbate the undertreatment of SUD. This study characterized the distribution of health care spending within families where a member has a SUD and estimated the association between HDHPs and family health care spending. METHODS: Using commercial claims and enrollment data from OptumLabs (2007-2017), we identified a treatment group of enrollees whose employers began offering an HDHP and comparison group whose employers never offered an HDHP. We used a difference-in-differences analysis that compared health care spending in families at firms that did vs. did not offer an HDHP before and after the HDHP offer. All models were adjusted for employer and year fixed effects, as well as family demographics, size, and chronic conditions. RESULTS: Our sample was comprised of 317,353 family-years. Family members with a SUD, on average, contributed an outsized proportion of total family health care expenditures (56.9% in a family of three). Offering a family HDHP was associated with a 6.1% reduction (95% confidence interval [CI]: 9.7-2.6%) in the probability of families having any SUD-related expenditures. The HDHP offer was associated with a $1546 reduction in family total expenditures and a $1185 reduction for the individual with SUD (95% CI: -2272 to -821 and -1845 to -525, respectively). CONCLUSIONS: The increased prevalence of family enrollment in HDHPs may further the existing issue of undertreatment of SUDs.

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

OBJECTIVES: Although high-deductible health plans (HDHPs) reduce health care spending, higher deductibles may lead to forgone care. Our goal was to determine the effects of HDHPs on the use of and spending on substance use disorder (SUD) services. STUDY DESIGN: We used difference-in-differences models to compare service use and spending for treating SUD among enrollees who were newly offered an HDHP relative to enrollees offered only traditional plan options throughout the study period. METHODS: We used deidentified commercial claims data from OptumLabs (2007-2017) to identify a sample of 28,717,236 person-years (2.2% with a diagnosed SUD). The main independent measure was an indicator for being offered an HDHP. The main dependent measures were the probability of (and spending associated with) using SUD services and specific treatment types. RESULTS: Enrollees were 6.6% (P < .001) less likely to use SUD services after being offered an HDHP relative to the comparison group. Reductions were concentrated in inpatient, intermediate, and ambulatory care, as well as medication use. Being offered an HDHP was associated with a decrease of 21% (P < .001) on health plan spending and an increase of 14% (P < .01) on out-of-pocket spending. CONCLUSIONS: Offering an HDHP was associated with a reduction in SUD service use and a shift in spending from the plan to the enrollee. In the context of the US drug epidemic, these study findings highlight a concern that the movement toward HDHPs may be exacerbating undertreatment of SUD.

Trends In Mental Health Care Delivery By Psychiatrists And Nurse Practitioners In Medicare, 2011-19.

The supply of psychiatrists in the United States is inadequate to address the unmet demand for mental health care. Psychiatric mental health nurse practitioners (PMHNPs) may fill the widening gap between supply of and demand for mental health specialists with prescribing privileges. Using Medicare claims for a 100 percent sample of fee-for-service beneficiaries (average age, sixty-one years) who had an office visit for either a psychiatrist or a PMHNP during the period 2011-19, we examined how the supply and use of psychiatrists and PMHNPs changed over time, and we compared their practice patterns. Psychiatrists and PMHNPs treated roughly comparable patient populations with similar services and prescriptions. From 2011 to 2019 the number of PMHNPs treating Medicare beneficiaries grew 162 percent, compared with a 6 percent relative decrease in the number of psychiatrists doing so. During the same period, total annual mental health office visits per 100 beneficiaries decreased 11.5 percent from 27.4 to 24.2, the net result of a 29.0 percent drop in psychiatrist visits being offset by a 111.3 percent increase in PMHNP visits. The proportion of all mental health prescriber visits provided by PMHNPs increased from 12.5 percent to 29.8 percent during 2011-19, exceeding 50 percent in rural, full-scope-of-practice regions. PMHNPs are a rapidly growing workforce that may be instrumental in improving mental health care access.

Association Between Telemedicine Use in Nonmetropolitan Counties and Quality of Care Received by Medicare Beneficiaries With Serious Mental Illness.

Importance: Access to specialty mental health care remains challenging for people with serious mental illnesses, such as schizophrenia and bipolar disorder. Whether expansion of telemedicine is associated with improved access and quality of care for these patients is unclear. Objective: To assess whether greater telemedicine use in a nonmetropolitan county is associated with quality measures, including use of specialty mental health care and medication adherence. Design, Setting, and Participants: In this cohort study, the variable uptake of telemental health visits was examined across a national sample of fee-for-service claims from Medicare beneficiaries in 2916 nonmetropolitan counties between January 1, 2010, and December 31, 2018. Beneficiaries with schizophrenia and related psychotic disorders and/or bipolar I disorder during the study period were included. For each year of the study, each county was categorized based on per capita telemental health service use (none, low, moderate, and high). The association between telemental health service use in the county and quality measures was tested using a multivariate model controlling for both patient characteristics and county fixed effects. Analyses were conducted from January 1 to April 11, 2022. Before the COVID-19 pandemic, telemedicine reimbursement was limited to nonmetropolitan beneficiaries. Main Outcomes and Measures: Receipt of a minimum of 2 specialty mental health service visits (telemedicine or in-person) in the year, number of months per year with medication, hospitalization rate, and outpatient follow-up visits after a mental health hospitalization in a year. Results: In 2018, there were 2916 counties with 118 170 patients (77 068 [65.2%] men; mean [SD] age, 58.3 [15.6] years) in the sample. The fraction of counties that had high telemental health service use increased from 2% in 2010 to 17% in 2018. In 2018 there were 1.08 telemental health service visits per patient in the high telemental health counties. Compared with no telemental health care in the county, patients in high-use counties were 1.2 percentage points (95% CI, 0.81-1.60 percentage points) (8.0% relative increase) more likely to have a minimum number of specialty mental health service visits, 13.7 percentage points (95% CI, 5.1-22.3 percentage points) (6.5% relative increase) more likely to have outpatient follow-up within 7 days of a mental health hospitalization, and 0.47 percentage points (95% CI, 0.25-0.69 percentage points) (7.6% relative increase) more likely to be hospitalized in a year. Telemental health service use was not associated with changes in medication adherence. Conclusions and Relevance: The findings of this study suggest that greater use of telemental health visits in a county was associated with modest increases in contact with outpatient specialty mental health care professionals and greater likelihood of follow-up after hospitalization. No substantive changes in medication adherence were noted and an increase in mental health hospitalizations occurred.

High-Deductible Health Plans Paired With Health Savings Accounts Increased Medication Cost Burden Among Individuals With Bipolar Disorder.

Objective: High-deductible health plans paired with health savings accounts (HSA-HDHPs) require substantial out-of-pocket spending for most services, including medications. We examined effects of HSA-HDHPs on medication out-of-pocket spending and use among people with bipolar disorder.Methods: This quasi-experimental study used claims data for January 2003 through December 2014. We studied a national sample of 348 members with bipolar disorder (defined based on International Classification of Diseases, 9th Revision), aged 12 to 64 years, who were continuously enrolled for 1 year in a low-deductible plan (≤ $500) then 1 year in an HSA-HDHP (≥ $1,000) after an employer-mandated switch. HSA-HDHP members were matched to 4,087 contemporaneous controls who remained in low-deductible plans. Outcome measures included out-of-pocket spending and use of bipolar disorder medications, non-bipolar psychotropics, and all other medications.Results: Mean pre-to-post out-of-pocket spending per person for bipolar disorder medications increased by 149.7% among HSA-HDHP versus control members (95% confidence interval [CI], 109.9% to 189.5%). Specifically, out-of-pocket spending increased for antipsychotics (220.9% [95% CI, 150.0% to 291.8%]) and anticonvulsants (109.6% [95% CI, 67.3% to 152.0%]). Both higher-income and lower-income HSA-HDHP members experienced increases in out-of-pocket spending for bipolar disorder medications (135.2% [95% CI, 86.4% to 184.0%] and 164.5% [95% CI, 100.9% to 228.1%], respectively). We did not detect statistically significant changes in use of bipolar disorder medications, non-bipolar psychotropics, or all other medications in this study population of HSA-HDHP members.Conclusions: HSA-HDHP members with bipolar disorder experienced substantial increases in out-of-pocket burdens for medications essential for their functioning and well-being. Although HSA-HDHPs were not associated with detectable reductions in medication use, high out-of-pocket costs could cause financial strain for lower-income enrollees.

A methodology for identifying behavioral health advanced practice registered nurses in administrative claims.

OBJECTIVE (STUDY QUESTION): Advanced practice registered nurses (APRNs) play an increased role in mental illness treatment. Health services research that uses claims to study mental health is often limited because behavioral health nurse practitioners (i.e., APRNs who specialize in mental illness, also known as psychiatric mental health APRNs) cannot be easily identified in claims data. We describe two methodologies to identify behavioral health APRNs in administrative claims. DATA SOURCES/STUDY SETTING (W/ HOSPITAL/INSTITUTION SETTING ANONYMIZED): We use 2010-2018 claims from the traditional Medicare fee-for-service program along with 2010-2019 commercial claims and Medicare Advantage data from the OptumLabs Data Warehouse (OLDW). Self-reported specialty data from the National Plan & Provider Enumeration System (NPPES) were used for validation. STUDY DESIGN: For each APRN, we calculated the percentage of visit diagnoses and of prescriptions in each database that were for mental health and classified those with ≥80% as behavioral health APRNs. We validated our definition with NPPES self-reported specialty for Medicare data. DATA COLLECTION/EXTRACTION METHODS: Not applicable. PRINCIPAL FINDINGS: Among APRNs with 10+ visits, 10,978 (8.1%) in Medicare and 9829 (11.7%) in commercial claims data met our visit-based criteria as behavioral health APRNs. Among APRNs with 10+ prescriptions, 8160 (6.2%) in Medicare and 16,538 (9.0%) in commercial claims data met our prescription-based criteria as behavioral health APRNs. Among the APRNs who self-reported they were behavioral health APRNs, 92.8% and 90.5% met our visit-based and prescription-based criteria, respectively. CONCLUSIONS: We present and validate two methods of identifying behavioral health APRNs in claims that can be used by other researchers.