Telepsychiatry Use Before and During the COVID-19 Pandemic Among Children Enrolled in Medicaid.

OBJECTIVE: This study examined telepsychiatry use among children enrolled in Medicaid before and during the COVID-19 pandemic. METHODS: A retrospective analysis was conducted of claims data from the Transformed Medicaid Statistical Information System for children (ages 3-17) with any mental health service use in 2019 (N=5,606,555) and 2020 (N=5,094,446). RESULTS: The number of children using mental health services declined by 9.1% from 2019 to 2020. Mental health services in all care settings (inpatient, outpatient, residential, emergency department, intensive outpatient/partial hospitalization) declined except for telehealth, which increased by 829.6%. In 2020, 44.5% of children using telehealth were non-Hispanic White, 16.1% were non-Hispanic Black, and 19.7% were Hispanic. Attention-deficit hyperactivity disorder, trauma, anxiety, depression, and behavior/conduct disorder were the most prevalent psychiatric diagnoses among children using telehealth services. CONCLUSIONS: Although telehealth use increased substantially in 2020, overall mental health service use declined among Medicaid-enrolled children. Telehealth may not fully address unmet mental health service needs.

National trends in buprenorphine prescribing before and during the COVID-19 pandemic.

OBJECTIVE: Recent studies have shown that early in the COVID-19 pandemic, rates of buprenorphine prescription dispensing for opioid use disorder (OUD) were relatively stable. However, whether that pattern continued later in the pandemic is unclear. This study examines the monthly rate of dispensed buprenorphine prescriptions during the early period and the later period of the pandemic. METHODS: The study uses interrupted time series analysis to examine buprenorphine prescription dispensed, average day's supply, payment source, and the number of patients with a dispensed buprenorphine prescription. The study utilized January 2019-April 2021 data from IQVIA National Prescription Audit, PayerTrack and Total Patient Tracker databases. RESULTS: After an initial increase in the number of patients prescribed buprenorphine in the early period of the pandemic, the monthly rate of patients prescribed buprenorphine increased at a lower rate compared to the pre-pandemic period (6100 vs 4600/month). The study observed a decline in the number of buprenorphine prescriptions dispensed both in levels and growth rate during the pandemic, but an increase occurred in the average day's supply of buprenorphine prescriptions (17 days pre-pandemic vs 18.6 day during the pandemic). Medicaid became the primary payer of buprenorphine prescriptions as the pandemic continued, while buprenorphine prescriptions paid for by private insurance declined. DISCUSSION: Expanding and maintaining access to treatment for OUD were key priorities in federal and state responses to the COVID-19 pandemic. The results of our study underscore the importance of policy efforts to help increase buprenorphine prescribing for OUD.

Is Bigger Better?: A Closer Look at Small Health Systems in the United States.

BACKGROUND: Research on US health systems has focused on large systems with at least 50 physicians. Little is known about small systems. OBJECTIVES: Compare the characteristics, quality, and costs of care between small and large health systems. RESEARCH DESIGN: Retrospective, repeated cross-sectional analysis. SUBJECTS: Between 468 and 479 large health systems, and between 608 and 641 small systems serving fee-for-service Medicare beneficiaries, yearly between 2013 and 2017. MEASURES: We compared organizational, provider and beneficiary characteristics of large and small systems, and their geographic distribution, using multiple Medicare and Internal Revenue Service administrative data sources. We used mixed-effects regression models to estimate differences between small and large systems in claims-based Healthcare Effectiveness Data and Information Set (HEDIS) quality measures and HealthPartners' Total Cost of Care measure using a 100% sample of Medicare fee-for-service claims. We fit linear spline models to examine the relationship between the number of a system's affiliated physicians and its quality and costs. RESULTS: The number of both small and large systems increased from 2013 to 2017. Small systems had a larger share of practice sites (43.1% vs. 11.7% for large systems in 2017) and beneficiaries (51.4% vs. 15.5% for large systems in 2017) in rural areas or small towns. Quality performance was lower among small systems than large systems (-0.52 SDs of a composite quality measure) and increased with system size up to ∼75 physicians. There was no difference in total costs of care. CONCLUSIONS: Small systems are a growing source of care for rural Medicare populations, but their quality performance lags behind large systems. Future studies should examine the mechanisms responsible for quality differences.

Sociodemographic differences in quality of treatment to Medicaid enrollees receiving buprenorphine.

Background: Buprenorphine is a key medication to treat opioid use disorder, but little is known about how treatment quality varies across sociodemographic groups. Objective: We examined measures of treatment quality and explored variation by sociodemographic factors. Methods: We used Medicaid MAX data from 50 states from 2006 to 2014 to identify buprenorphine treatment episodes (N = 317,494). We used multivariable logistic regression to examine the quality of buprenorphine treatment along four dimensions: (1) sufficient duration, (2) effective dosage, and concurrent prescribing of (3) opioid analgesics and (4) benzodiazepines. We explored how quality varied by race/ethnicity, age, sex, and urbanicity. Results: In adjusted models, compared to non-Hispanic White individuals, non-Hispanic Black and Hispanic individuals had lower odds of receiving effective dosage (aORs = 0.79 and 0.89, respectively) and sufficient duration (aORs = 0.64 and 0.71, respectively), and lower odds of concurrent prescribing of opioid analgesics (aORs = 0.86 and 0.85, respectively) and benzodiazepines (aORs = 0.51 and 0.59, respectively). Older individuals had higher odds of sufficient duration (aORs from 1.21-1.33), but also had higher odds of concurrent opioid analgesics prescribing (aORs from 1.29-1.56) and benzodiazepines (aORs from 1.44-1.99). Females had higher odds of sufficient duration (aOR = 1.12), but lower odds of effective dosage (aOR = 0.77) and higher odds of concurrent prescribing of opioid analgesics (aOR = 1.25) and benzodiazepines (aOR = 1.16). Compared to individuals living in metropolitan areas, individuals living in non-metropolitan areas had higher odds of sufficient duration (aORs = 1.11 and 1.24) and effective dosage (aORs = 1.06 and 1.33), and lower odds of concurrent prescribing (aORs from 0.81-0.98). Conclusions: Black and Hispanic individuals were less likely to receive effective buprenorphine dosage and sufficient duration. Quality results were mixed for older and female individuals; although these individuals were more likely to receive treatment of sufficient duration, they were also more likely to be concurrently prescribed potentially contraindicated medications, and females were less likely to receive effective dosage. Findings raise concerns about adequacy of care for minority and other at-risk populations.

Rapid Discontinuation of Chronic, High-Dose Opioid Treatment for Pain: Prevalence and Associated Factors.

PURPOSE: To examine the prevalence of rapid discontinuation of chronic, high-dose opioid analgesic treatment, and identify associated patient, clinician, and community factors. METHODS: Using 2017-2018 retail pharmacy claims data from IQVIA, we identified chronic, high-dose opioid analgesic treatment episodes discontinued during these years and determined the percent of episodes meeting criteria for rapid discontinuation. We used multivariable logistic regression to estimate the probability of rapid discontinuation, conditional on having a discontinued chronic, high-dose opioid treatment episode, as a function of patient, provider, and county characteristics. RESULTS: We identified 810,120 new, chronic, high-dose opioid treatment episodes discontinued in 2017 or 2018, of which 72.0% (n=583,415) were rapidly discontinued. Rapid discontinuation was significantly more likely among Medicare (aOR 1.14, 95% CI 1.12 to 1.15) and Medicaid enrollees (aOR 1.03, 95% CI 1.02 to 1.05) compared to the commercially insured; in counties with higher fatal overdose rates (aOR 1.03, 95% CI 1.01 to 1.04) compared to counties with the lowest fatal overdose rates; and in counties with a higher percentage of non-white residents (aOR 1.21 for counties in the highest quartile relative to the lowest, 95% CI 1.19 to 1.24). Likelihood of rapid discontinuation also varied by prescriber specialty. CONCLUSIONS: Most chronic, high-dose opioid treatment episodes that ended in 2017 or 2018 were discontinued more rapidly than recommended by clinical guidelines, raising concerns about adverse patient outcomes. Our findings highlight the need to understand what drives discontinuation and to inform safer opioid tapering and discontinuation practices.

Smartphone Application Allowing Physicians to Call Patients Associated with Increased Physician Productivity.

BACKGROUND: Telehealth and other technologies that enable remote patient-physician communication technologies have widespread use among physicians and other health care providers, but the impacts of these technologies on physician productivity are not well known. OBJECTIVE: To determine whether a HIPAA-compliant application that allows physicians to call patients from their personal cell phones is associated with an increase in physician productivity. DESIGN, SETTING, AND PARTICIPANTS: We used a 100% sample of Medicare claims and longitudinal physician-level data to examine whether physician use of a smartphone application that enables physician-patient phone calls is associated with changes in Medicare patient volume and services. We compared early adopters of the application, 31,577 physicians providing Part B services who initiated use of the application between January 2014 and December 2017, with later adopters, 22,988 physicians who initiated use between January 2018 and July 2019. MAIN MEASURES: Physician productivity was measured as total Medicare Part B beneficiaries, total Part B services provided, the number of Part B beneficiaries with any evaluation and management (E&M) service, the total number of E&M services provided, and the average number of E&M services provided per beneficiary. KEY RESULTS: Following application use, there was a 0.52 increase (95% CI: 0.19 to 0.85) in the monthly number of Part B beneficiaries seen. This difference translates to a 0.8% increase in Part B beneficiaries. Similar increases were observed for the number of unique beneficiaries for which the physician provided E&M services-a 0.50 increase (95% CI: 0.27 to 0.73) or 1.2%. There was a 0.43 increase (95% CI: 0.07 to 0.78) in monthly E&M services (0.7% increase). CONCLUSIONS: Physicians who used a freely available smartphone application modestly increased their total Medicare beneficiary volume and total number of E&M services provided, suggesting potential improvements in physician productivity.

Opioid use in older adults and Medicare Part D.

OBJECTIVE: To determine whether the introduction of prescription drug coverage under Medicare Part D increased opioid prescriptions, patient care-seeking for pain, and pain diagnoses among elderly Medicare-eligible adults. STUDY SETTING: Office visits by adults aged 18 years or older from the 2000-2016 National Ambulatory Medical Care Survey (12 375 207 253 office visits), and respondents from the 2000-2017 Medical Expenditure Panel Survey (4 023 418 681 individuals). STUDY DESIGN: We compared care-seeking for pain, provider-assigned pain diagnoses, and opioid prescriptions before and after the Medicare eligibility age of 65, and before and after Part D's implementation using a regression discontinuity, difference-in-differences design. Analyses were adjusted for age, sex, race, and year. PRINCIPAL FINDINGS: Patient care-seeking for pain increased by 11.4 office visits per 100 people (95% confidence interval 2.0-20.8), or 29%, in response to the implementation of Part D. Opioid prescriptions and diagnoses of pain-related conditions did not change significantly, but the financing of opioid prescriptions shifted from private to public payers at age 65. CONCLUSIONS: The introduction of Medicare Part D was not associated with increased opioid use among older adults. Rather, opioid use among the elderly has been driven by high levels of opioid use among commercially insured adults who subsequently age into Medicare. Our findings raise the question of whether more judicious prescribing to younger adults coupled with concerted efforts to deprescribe opioids when appropriate may prevent problematic opioid use among the elderly.

Health system changes under pay-for-performance: the effects of Rwanda's national programme on facility inputs.

Pay-for-performance (P4P) programmes have been introduced in numerous developing countries with the goal of increasing the provision and quality of health services through financial incentives. Despite the popularity of P4P, there is limited evidence on how providers achieve performance gains and how P4P affects health system quality by changing structural inputs. We explore these two questions in the context of Rwanda's 2006 national P4P programme by examining the programme's impact on structural quality measures drawn from international and national guidelines. Given the programme's previously documented success at increasing institutional delivery rates, we focus on a set of delivery-specific and more general structural inputs. Using the programme's quasi-randomized roll-out, we apply multivariate regression analysis to short-run facility data from the 2007 Service Provision Assessment. We find positive programme effects on the presence of maternity-related staff, the presence of covered waiting areas and a management indicator and a negative programme effect on delivery statistics monitoring. We find no effects on a set of other delivery-specific physical resources, delivery-specific human resources, delivery-specific operations, general physical resources and general human resources. Using mediation analysis, we find that the positive input differences explain a small and insignificant fraction of P4P's impact on institutional delivery rates. The results suggest that P4P increases provider availability and facility operations but is only weakly linked with short-run structural health system improvements overall.

A Note on the Comparative Statics of Pay-for-Performance in Health Care.

Pay-for-performance (P4P) is a widely implemented quality improvement strategy in health care that has generated much enthusiasm, but only limited empirical evidence to support its effectiveness. Researchers have speculated that flawed program designs or weak financial incentives may be to blame, but the reason for P4P's limited success may be more fundamental. When P4P rewards multiple services, it creates a special case of the well-known multitasking problem, where incentives to increase some rewarded activities are blunted by countervailing incentives to focus on other rewarded activities: these incentives may cancel each other out with little net effect on quality. This paper analyzes the comparative statics of a P4P model to show that when P4P rewards multiple services in a setting of multitasking and joint production, the change in both rewarded and unrewarded services is generally ambiguous. This result contrasts with the commonly held intuition that P4P should increase rewarded activities.