Escalating costs of self-injury mortality in the 21st century United States: an interstate observational study.

BACKGROUND: Estimating the economic costs of self-injury mortality (SIM) can inform health planning and clinical and public health interventions, serve as a basis for their evaluation, and provide the foundation for broadly disseminating evidence-based policies and practices. SIM is operationalized as a composite of all registered suicides at any age, and 80% of drug overdose (intoxication) deaths medicolegally classified as 'accidents,' and 90% of corresponding undetermined (intent) deaths in the age group 15 years and older. It is the long-term practice of the United States (US) Centers for Disease Control and Prevention (CDC) to subsume poisoning (drug and nondrug) deaths under the injury rubric. This study aimed to estimate magnitude and change in SIM and suicide costs in 2019 dollars for the United States (US), including the 50 states and the District of Columbia. METHODS: Cost estimates were generated from underlying cause-of-death data for 1999/2000 and 2018/2019 from the US Centers for Disease Control and Prevention's (CDC's) Wide-ranging ONline Data for Epidemiologic Research (WONDER). Estimation utilized the updated version of Medical and Work Loss Cost Estimation Methods for CDC's Web-based Injury Statistics Query and Reporting System (WISQARS). Exposures were medical expenditures, lost work productivity, and future quality of life loss. Main outcome measures were disaggregated, annual-averaged total and per capita costs of SIM and suicide for the nation and states in 1999/2000 and 2018/2019. RESULTS: 40,834 annual-averaged self-injury deaths in 1999/2000 and 101,325 in 2018/2019 were identified. Estimated national costs of SIM rose by 143% from $0.46 trillion to $1.12 trillion. Ratios of quality of life and work losses to medical spending in 2019 US dollars in 2018/2019 were 1,476 and 526, respectively, versus 1,419 and 526 in 1999/2000. Total national suicide costs increased 58%-from $318.6 billion to $502.7 billion. National per capita costs of SIM doubled from $1,638 to $3,413 over the observation period; costs of the suicide component rose from $1,137 to $1,534. States in the top quintile for per capita SIM, those whose cost increases exceeded 152%, concentrated in the Great Lakes, Southeast, Mideast and New England. States in the bottom quintile, those with per capita cost increases below 70%, were located in the Far West, Southwest, Plains, and Rocky Mountain regions. West Virginia exhibited the largest increase at 263% and Nevada the smallest at 22%. Percentage per capita cost increases for suicide were smaller than for SIM. Only the Far West, Southwest and Mideast were not represented in the top quintile, which comprised states with increases of 50% or greater. The bottom quintile comprised states with per capita suicide cost increases below 24%. Regions represented were the Far West, Southeast, Mideast and New England. North Dakota and Nevada occupied the extremes on the cost change continuum at 75% and - 1%, respectively. CONCLUSION: The scale and surge in the economic costs of SIM to society are large. Federal and state prevention and intervention programs should be financed with a clear understanding of the total costs-fiscal, social, and personal-incurred by deaths due to self-injurious behaviors.

Association of State Social and Environmental Factors With Rates of Self-injury Mortality and Suicide in the United States.

Importance: Self-injury mortality (SIM) combines suicides and the preponderance of drug misuse-related overdose fatalities. Identifying social and environmental factors associated with SIM and suicide may inform etiologic understanding and intervention design. Objective: To identify factors associated with interstate SIM and suicide rate variation and to assess potential for differential suicide misclassification. Design, Setting, and Participants: This cross-sectional study used a partial panel time series with underlying cause-of-death data from 50 US states and the District of Columbia for 1999-2000, 2007-2008, 2013-2014 and 2018-2019. Applying data from the Centers for Disease Control and Prevention, SIM includes all suicides and the preponderance of unintentional and undetermined drug intoxication deaths, reflecting self-harm behaviors. Data were analyzed from February to June 2021. Exposures: Exposures included inequity, isolation, demographic characteristics, injury mechanism, health care access, and medicolegal death investigation system type. Main Outcomes and Measures: The main outcome, SIM, was assessed using unstandardized regression coefficients of interstate variation associations, identified by the least absolute shrinkage and selection operator; ratios of crude SIM to suicide rates per 100 000 population were assessed for potential differential suicide misclassification. Results: A total of 101 325 SIMs were identified, including 74 506 (73.5%) among males and 26 819 (26.5%) among females. SIM to suicide rate ratios trended upwards, with an accelerating increase in overdose fatalities classified as unintentional or undetermined (SIM to suicide rate ratio, 1999-2000: 1.39; 95% CI, 1.38-1.41; 2018-2019: 2.12; 95% CI, 2.11-2.14). Eight states recorded a SIM to suicide rate ratio less than 1.50 in 2018-2019 vs 39 states in 1999-2000. Northeastern states concentrated in the highest category (range, 2.10-6.00); only the West remained unrepresented. Least absolute shrinkage and selection operator identified 8 factors associated with the SIM rate in 2018-2019: centralized medical examiner system (ß = 4.362), labor underutilization rate (ß = 0.728), manufacturing employment (ß = -0.056), homelessness rate (ß = -0.125), percentage nonreligious (ß = 0.041), non-Hispanic White race and ethnicity (ß = 0.087), prescribed opioids for 30 days or more (ß = 0.117), and percentage without health insurance (ß = -0.013) and 5 factors associated with the suicide rate: percentage male (ß = 1.046), military veteran (ß = 0.747), rural (ß = 0.031), firearm ownership (ß = 0.030), and pain reliever misuse (ß = 1.131). Conclusions and Relevance: These findings suggest that SIM rates were associated with modifiable, upstream factors. Although embedded in SIM, suicide unexpectedly deviated in proposed social and environmental determinants. Heterogeneity in medicolegal death investigation processes and data assurance needs further characterization, with the goal of providing the highest-quality reports for developing and tracking public health policies and practices.

Long-Term Trends in Black and White Mortality in the Rural United States: Evidence of a Race-Specific Rural Mortality Penalty.

PURPOSE: The rural mortality penalty-growing disparities in rural-urban macro-level mortality rates-has persisted in the United States since the mid 1980s. Substantial intrarural differences exist: rural places of modest population size, close to urban areas, experience a greater mortality burden than the most rural locales. This research builds on recent findings by examining whether a race-specific rural mortality penalty exists; that is, are some rural areas more detrimental to black and/or white mortality than others? METHODS: Using data from the Compressed Mortality File from 1968 to 2012, we calculate annual age-adjusted, race-specific mortality rates for all rural-urban regions designated by the Rural-Urban Continuum Codes. Indicators for population, socioeconomic status, and health infrastructure, as a proxy for access to care, are used as predictors of race-specific mortality in multivariable regression models. FINDINGS: Three important results emerge from this analysis: (1) there is a substantial mortality disadvantage for both black and white rural Americans, (2) the most advantageous regions of mortality for blacks exhibit higher mortality than the most disadvantageous regions for whites, and (3) access to health care is a much stronger predictor of white mortality than black mortality. CONCLUSIONS: The rural mortality penalty is evident in race-specific mortality trends over time, with an added disadvantage in black mortality. The rate of mortality improvement for rural blacks and whites lags behind their same-race, urban counterparts, creating a diverging gap in race-specific mortality trends in rural America.

Career expectancy of physicians active in patient care: evidence from Mississippi.

INTRODUCTION: Physician shortages in the USA, an issue that has been particularly challenging in Mississippi, have been a concern among health scholars and policy makers for several decades. Physician shortages hinder residents from easily obtaining routine care, potentially magnifying health disparities. This study examines physician career life expectancy, or how long physicians typically practice, in Mississippi. METHODS: Data on Mississippi's physician population actively involved between 2007 and 2011 were obtained from the Mississippi State Board of Medical Licensure. Abridged career life tables were constructed for all Mississippi physicians and population subgroups based on practice specialty, gender, race, urban-rural practice, and health professional shortage area status. RESULTS: Upon entry into practice in Mississippi, physicians practiced for about 14.4 years. Rural physicians, primary care physicians, minority physicians, physicians practicing in health professional shortage areas, and men had the longest career expectancies. Physicians who are women or who practice in urban counties were substantially more likely to exit practice compared to all other subgroups examined. The odds of remaining in practice were significantly different based on gender, race, urban-rural practice county, and health professional shortage area status. CONCLUSIONS: The first 5 years of practice are the most critical regarding retention for all physicians, regardless of practice specialty, gender, race, urban-rural status, or health professional shortage area status.

Access to primary care physicians differs by health insurance coverage in Mississippi.

OBJECTIVES: The objective of the study was to measure how access to primary health care in Mississippi varies by type of health insurance. METHODS: We called primary care physician (general practitioner, family practice, internal medicine, obstetrics/gynecology, and pediatric) offices in Mississippi three times, citing different types of health insurance coverage in each call, and asked for a new patient appointment with a physician. RESULTS: Of all of the offices contacted, 7% of offices were not currently accepting new patients who had private insurance, 15% of offices were not currently accepting new Medicare patients, 38% were not currently accepting new Medicaid patients, and 9% to 21% of office calls were unresolved in one telephone call to the office. CONCLUSIONS: Access to health insurance does not ensure access to primary health care; access varies by type of health insurance coverage.

The rise and fall of medicaid managed care in Mississippi: lessons for public health policy makers.

This article describes the development, implementation, and termination of a primary care case management program in the State of Mississippi. The study provides policy makers with critical information as to factors associated with successful implementation of current health care initiatives.

Policy, autonomy, and physician satisfaction.

It is important to understand how policy influences physician satisfaction, which in turn affects access to and quality of care. Two Mississippi policy crises in the past decade indirectly jeopardized its primary health care supply. During a volatile malpractice climate in 2002, physician groups claimed physicians would retire or relocate or quit medicine entirely. The second crisis in 2005 temporarily shut down Medicaid reimbursement. Both crises had the capacity to undermine physician satisfaction, a predictor of physician retention. We used data from two cross-sectional Mississippi physician surveys to test how malpractice experiences and Medicaid reimbursement influenced physician satisfaction. The Medicaid shutdown had no measurable effect on physician satisfaction, while the immediate effects of a litigious malpractice climate dampened physician satisfaction. However, the data indicate that the effects of malpractice experiences may be quite short-lived.

Mississippi burnout. Part I: Personal characteristics and practice context.

Research suggests that practice conditions can predict burnout, which is an important factor in physician performance and career choices. Understanding the personal characteristics and practice contexts that heighten burnout risk is a first step toward interventions that could minimize burnout. This study describes how burnout differs, across characteristics and contexts, among a sample of Mississippi physicians. Data are from an online survey of all licensed Mississippi physicians with unique email addresses. Roughly one-quarter of physicians responding to the burnout question reported burnout and more than half reported feeling stressed. Middle-aged (40-59) physicians report higher levels of burnout than their younger and older counterparts. Physicians who are self-employed also report higher levels of burnout than salaried physicians. Physicians reporting regional perceived workforce shortages, especially in mental health practices, also reported significantly higher burnout levels. We discuss the implications of our findings for devising strategies to reduce burnout and retain qualified health care providers for Mississippi residents.

Evaluating heart disease presciptions-filled as a proxy for heart disease prevalence rates.

Heart disease is the leading cause of death in the U.S. Yet, prevalence rates are not reported at the county level. Not knowing how many have the disease, and where they are, may be a knowledge barrier to effective health care interventions. We use heart disease drug prescriptions-filled as a proxy measure for prevalence of heart disease. We test the correlation to the Behavioral Risk Factor Surveillance System (BRFSS) and find positive, statistically significant correlations. Next we illustrate the geographic patterns revealed using the county-level prevalence estimate maps. This information can be used to provide a better understanding of sub-state variations in disease patterns and subsequently target the delivery of health resources to small areas in need.

Perspectives on Mississippi's 21st century Physician Workforce Supply: findings from the 2007 MSMD survey.

The capacity to recruit and retain physicians to practice in Mississippi has been a perennial concern of the profession. In the first Mississippi Physician Workforce Study (2003) conducted at the height of the state 'malpractice crisis,' Professor Cossman identified several looming threats to effective Mississippi physician recruitment and retention, including a high percentage of physicians who reported they were considering relocation or retirement in the near future. In this article, Street and Cossman report survey findings from actively practicing physicians (N=848) who responded to the second Mississippi Physician Workforce Study (2007 MSMD). This analysis updates perspectives on the physician workforce supply in the aftermath of malpractice legislative reform and Hurricane Katrina.

Medicaid reimbursement and access to physicians: does lower reimbursement mean less access to care?

AIn 2002, Medicaid reimbursement rates were lowered. Stakeholders expressed concern that physicians would be less likely to accept Medicaid patients at the lower reimbursement rate and, consequently, Medicaid patients would have to drive farther for care. Results presented here tested those two propositions using claims data from the Mississippi Division of Medicaid. We found physicians just as likely to participate in the Medicaid program after the reimbursement rate decrease, but with higher patient loads. And, although Medicaid patients must drive farther for their care than the general population, their drive times were highest in 2002 but declined to 2001 levels by 2003. Any negative impacts from the reimbursement rate decrease on access to care for Medicaid beneficiaries appear to have been temporary. Long-term effects can be assessed with more recent claims data.

Mississippi's physician labor force: current status and future challenges.

The literature review indicates that changes in Medicaid/Medicare reimbursement, large numbers of uninsured patients, the legal climate, and largely rural and chronically ill populations create a challenging environment for physicians practicing in Mississippi. As a largely rural state, many Mississippians find medical care to be physically distant, with most care being concentrated in a couple areas of the state. Given these factors, the legal climate in Mississippi and the top relocation decision factors, Mississippi will be further challenged in recruiting and retaining the numbers of general practitioners and specialists necessary to provide care to the state's population. The challenges that physicians are facing have led to challenges for health policy makers, in that physicians are difficult to recruit to Mississippi and, once here, difficult to retain as practitioners throughout their career. Four datasets were used in conjunction to analyze the demographic characteristics of Mississippi's physicians, including the age structure disaggregated by several other variables. Ultimately, the results were extended to impacts of recruitment, relocations, and retirement decisions of physicians who participated in the MSMDS. Briefly, demographic results indicate that Mississippi has a largely white physician population serving a nearly 40% minority population in Mississippi. The under representation of women within the medical profession in Mississippi means that women in the state might find it unusually challenging to find a female physician, particularly in rural areas where access to physicians is more limited in the first place. Mississippi has a high concentration of African-American patients with a low African-American physician presence. The proportion of physicians who are female is on the rise nationwide and within Mississippi, largely due to increasing enrollments of women in medical schools. Though variations exist within the groups of physicians identified as generalists, Mississippi is only slightly more likely than the nation to have specialists, rather than generalists (see Table Seven). Age structure analysis indicates that Delta physicians are older than physicians elsewhere in the state, that urban physicians are younger than rural physicians, and that our physician labor force is more highly concentrated between the ages of 35 and 54 than in the nation as a whole. Analyses concerning the future of the physician labor force indicate that a near majority of Mississippi's practicing physicians received their MD degree at UMC, but younger physicians are more likely to have been educated out-of-state than older physicians. Those who received their degrees elsewhere and chose to practice in Mississippi are more likely to be specialists (60%) than generalists (40%). Those physicians practicing in the state who were educated in-state are nearly equally as likely to be generalists (47%) as they are to be specialists (53%). Additionally, those approaching retirement are more likely to be generalists, yet the state is recruiting more generalists from recent medical school classes than in the past. Variations in intentions to recruit, relocate, and retire exist. However, most of the substantively important variation is across age groups and time in practice. There is little relevance of specialty or location within the state when examining variation in recruitment, relocation or retirement plans. Given the findings, policy research recommendations focus on improving the retention of UMC's graduates for practice in the state, improving retention of active physicians, increasing the recruitment of physicians from out of state, and easing difficulties associated with working part-time as a step toward retirement. With these changes in policy, it is possible that Mississippi can thwart a physician workforce shortage; however, without changes, with more physicians relocating, retiring early, or opting out of practicing in the state, the extant physician shortage will become more severe. Furthermore, without the data collection efforts mentioned here, there will be no means to assess whether policy changes are actually impacting the physician labor force.