How Should the Use of Opioids Be Regulated to Motivate Better Clinical Practice?

This article describes historical and political reasons for-and devastating consequences of-US opioid prescribing policy since the 1990s, which has restricted opioid prescribing for pain less than for treating opioid use disorder (OUD) treatment. This article considers merits and drawbacks of a new diagnostic category and proposes a regulatory and clinical framework for prescribing long-term opioid therapy for pain and for prescribing opioids to treat OUD.

Using an Equity in Research Framework to Develop a Community-Engaged Intervention to Improve Preexposure Uptake Among Black Women Living in the United States South.

ABSTRACT: In the U.S. South, over half of new HIV diagnoses occur among Black Americans with research lagging for women who face increased HIV rates and low PrEP uptake, among other health inequities. Community engaged research is a promising method for reversing these trends with established best practices for building infrastructure, implementing research, and translating evidence-based interventions into clinical and community settings. Using the 5Ws of Racial Equity in Research Framework (5Ws) as a racial equity lens, the following paper models a review of a salon-based intervention to improve PrEP awareness and uptake among Black women that was co-developed with beauty salons, stylists, and Black women through an established community advisory council. In this paper we demonstrate how the 5Ws framework was applied to review processes, practices, and outcomes from a community-engaged research approach. The benefits of and challenges to successful collaboration are discussed with insights for future research and community impact.

Emergency Department Visits And Hospital Capacity In The US: Trends In The Medicare Population During The COVID-19 Pandemic.

Although emergency department (ED) and hospital overcrowding were reported during the later parts of the COVID-19 pandemic, the true extent and potential causes of this overcrowding remain unclear. Using data on the traditional fee-for-service Medicare population, we examined patterns in ED and hospital use during the period 2019-22. We evaluated trends in ED visits, rates of admission from the ED, and thirty-day mortality, as well as measures suggestive of hospital capacity, including hospital Medicare census, length-of-stay, and discharge destination. We found that ED visits remained below baseline throughout the study period, with the standardized number of visits at the end of the study period being approximately 25 percent lower than baseline. Longer length-of-stay persisted through 2022, whereas hospital census was considerably above baseline until stabilizing just above baseline in 2022. Rates of discharge to postacute facilities initially declined and then leveled off at 2 percent below baseline in 2022. These results suggest that widespread reports of overcrowding were not driven by a resurgence in ED visits. Nonetheless, length-of-stay remains higher, presumably related to increased acuity and reduced available bed capacity in the postacute care system.

Use Of High- And Low-Value Health Care Among US Adults, By Income, 2010-19.

Health care payment reforms in the US have aimed to encourage the use of high-value care while discouraging the use of low-value care. However, little is known about whether the use of high- and low-value care differs by income level. Using data from the 2010-19 Medical Expenditure Panel Survey, we examined the use of specified types of high- and low-value care by income level. We found that high-income adults were significantly more likely than low-income adults to use nearly all types of high-value care. Findings were consistent across age categories, although differences by income level in the use of high-value care were smaller among the elderly. Our analysis of differences in the use of low-value care had mixed results. Among nonelderly adults, significant differences between those with high and low incomes were found for five of nine low-value services, and among elderly adults, significant differences by income level were found for three of twelve low-value services. Understanding the mechanisms underlying these disparities is crucial to developing effective policies and interventions to ensure equitable access to high-value care and discourage low-value services for all patients, regardless of income.

Most States Allow Medicaid Managed Care Plans Discretion To Restrict Substance Use Disorder Treatment Benefits.

Managed care plans, which contract with states to cover three-quarters of Medicaid enrollees, play a crucial role in addressing the drug epidemic in the United States. However, substance use disorder benefits vary across Medicaid managed care plans, and it is unclear what role states play in regulating their activities. To address this question, we surveyed thirty-three states and Washington, D.C., regarding their substance use disorder treatment coverage and utilization management requirements for Medicaid managed care plans in 2021. Most states mandated coverage of common forms of substance use disorder treatment and prohibited annual maximums and enrollee cost sharing in managed care. Fewer than one-third of states forbade managed care plans from imposing prior authorization for each treatment service. For most treatment medications, fewer than two-thirds of states prohibited prior authorization, drug testing, "fail first," or psychosocial therapy requirements in managed care. Our findings suggest that many states give managed care plans broad discretion to impose requirements on covered substance use disorder treatments, which may affect access to lifesaving care.

Vaccine Politics.

A vaccine law and policy expert reflects on the dangers of the influence of politics on public health decision making.

The COVID-19 Uninsured Program: Nearly 39 Million Vaccine Doses Were Funded, 2020-22.

The COVID-19 Uninsured Program, administered by the Health Resources and Services Administration (HRSA), reimbursed providers for administering COVID-19 vaccines to uninsured US adults from December 11, 2020, through April 5, 2022. Using HRSA claims data covering forty-two states, we estimated that the program funded about 38.9 million COVID-19 vaccine doses, accounting for 5.7 percent of total doses distributed and 10.9 percent of doses administered to adults ages 19-64.

In-Home Health Risk Assessments And Chart Reviews Contribute To Coding Intensity In Medicare Advantage.

There is widespread agreement that taxpayers pay more when Medicare beneficiaries are enrolled in Medicare Advantage (MA) plans than if those beneficiaries were enrolled in traditional Medicare. MA plans are paid on the basis of submitted diagnoses and thus have a clear incentive to encourage providers to find and report as many diagnoses for their enrollees as possible. Two mechanisms that MA plans use to identify diagnoses that are not available for beneficiaries in traditional Medicare are in-home health risk assessments and chart reviews. Using MA encounter data for 2015-20, I isolated the impact of these two types of encounters on the risk scores used for payments to MA plans during 2016-21. I found that encounter-based risk scores for MA enrollees were higher by 0.091 points, or 7.4 percent, in 2021 when in-home health risk assessments and chart reviews were included than they would have been without the use of these tools.

The Road To Value Can't Be Paved With A Broken Medicare Physician Fee Schedule.

Value-based payment has been promoted for increasing quality, controlling spending, and improving patient and practitioner experience. Meanwhile, needed reforms to fee-for-service payment (the Medicare Physician Fee Schedule) have been ignored as policy makers seek to move payment toward alternatives, even though the fee schedule is an intrinsic part of Alternative Payment Models. In this article, we show how value-based payment and the fee schedule should be viewed as complementary, rather than as separate silos. We trace the origins of embedded flaws in the fee schedule that must be fixed if value-based payment is to succeed. These include payment distortions that directly compromise value by overpaying for certain procedures and imaging services while underpaying for services that add value for beneficiaries. We also show how the fee schedule can accommodate bundled payments and population-based payments that are central to Alternative Payment Models. We draw two conclusions. First, the Centers for Medicare and Medicaid Services should correct misvalued services and establish a hybrid payment for primary care that blends fee-for-service and population-based payment. Second, Congress should alter the thirty-five-year-old statutory basis for setting Medicare fees to allow CMS to explicitly consider policy priorities such as workforce shortages in refining fee levels.

Overlap In Carriers And Networks In Medicaid And The Individual Marketplaces.

As people lose Medicaid because of the end of the COVID-19 public health emergency, many states will route former Medicaid managed care enrollees into Affordable Care Act Marketplace coverage with the same carrier. In 2021, 52.1 percent of Medicaid managed care enrollees were enrolled by a carrier that also had a plan on the Marketplace in the same county.

The COVID-19 Pandemic Led To A Large Decline In Physician Gross Revenue Across All Specialties In 2020.

US health care use declined during the initial phase of the COVID-19 pandemic in 2020. Although utilization is known to have recovered in 2021 and 2022, it is unknown how revenue in 2020-22 varied by physician specialty and practice setting. This study linked medical claims from a large national federation of commercial health plans to physician and practice data to estimate pandemic-associated impacts on physician revenue (defined as payments to eligible physicians) by specialty and practice characteristics. Surgical specialties, emergency medicine, and medical subspecialties each experienced a greater than 9 percent adjusted gross revenue decline in 2020 relative to prepandemic baselines. By 2022, pathology and psychiatry revenue experienced robust recovery, whereas surgical and oncology revenue remained at or below baseline. Revenue recovery in 2022 was greater for physicians practicing in hospital-owned practices and in practices participating in accountable care organizations. Pandemic-associated revenue recovery in 2021 and 2022 varied by specialty and practice type. Given that physician financial instability is associated with health care consolidation and leaving practice, policy makers should closely monitor revenue trends among physicians in specialties or practice settings with sustained gross revenue reductions during the pandemic.

The Effect Of Next Generation Accountable Care Organizations On Medicare Expenditures.

The Next Generation Accountable Care Organization (NGACO) model (active during 2016-21) tested the effects of high financial risk, payment mechanisms, and flexible care delivery on health care spending and value for fee-for-service Medicare beneficiaries. We used quasi-experimental methods to examine the model's effects on Medicare Parts A and B spending. Sixty-two ACOs with more than 4.2 million beneficiaries and more than 91,000 practitioners participated in the model. The model was associated with a $270 per beneficiary per year, or approximately $1.7 billion, decline in Medicare spending. After shared savings payments to ACOs were included, the model increased net Medicare spending by $56 per beneficiary per year, or $96.7 million. Annual declines in spending for the model grew over time, reflecting exit by poorer-performing NGACOs, improvement among the remaining NGACOs, and the COVID-19 pandemic. Larger declines in spending occurred among physician practice ACOs and ACOs that elected population-based payments and risk caps greater than 5 percent.

Evolution of HIV Health Care Workforce Needs in the U.S. Mountain West During the COVID-19 Pandemic: A Mixed Method Study.

ABSTRACT: The COVID-19 pandemic drastically affected health care delivery for vulnerable populations. Many facilities shifted services to telemedicine, and people with HIV or at risk of acquiring HIV experienced interruptions in care. Simultaneously, traditional training approaches to help providers adapt were disrupted. Using a mixed method approach to examine changes over time, we integrated data on trainee needs collected by the Mountain West AIDS Education and Training Center (AETC): a 10-state needs assessment survey in 2020; feedback from a 2020 community of practice; aggregate training data from 2000 to 2022; and a second survey in 2022. HIV care providers' training needs evolved from wanting support on telemedicine and COVID-19 patient care issues, to a later focus on mental health and substance use, social determinants of health, and care coordination. This integrative analysis demonstrates the vital role that AETCs can play in addressing evolving and emergent public health challenges for the HIV workforce.

Tiny patients, huge impact: a call to action.

The continuation of high-quality care is under threat for the over 70 million children in the United States. Inequities between Medicaid and Medicare payments and the current procedural-based reimbursement model have resulted in the undervaluing of pediatric medical care and lack of prioritization of children's health by institutions. The number of pediatricians, including pediatric subspecialists, and pediatric healthcare centers are declining due to mounting financial obstacles and this crucial healthcare supply is no longer able to keep up with demand. The reasons contributing to these inequities are clear and rational: Medicaid has significantly lower rates of reimbursement compared to Medicare, yet Medicaid covers almost half of children in the United States and creates the natural incentive for medical institutions to prioritize the care of adults. Additionally, certain aspects of children's healthcare are unique from adults and are not adequately covered in the current payment model. The result of decades of devaluing children's healthcare has led to a substantial decrease in the availability of services, medications, and equipment needed to provide healthcare to children across the nation. Fortunately, the solution is just as clear as the problem: we must value the healthcare of children as much as that of adults by increasing Medicaid funding to be on par with Medicare and appreciate the complexities of care beyond procedures. If these changes are not made, the high-quality care for children in the US will continue to decline and increase strain on the overall healthcare system as these children age into adulthood.

Economic Burden of Medically Attended Respiratory Syncytial Virus Infections Among Privately Insured Children Under 5 Years of Age in the USA.

BACKGROUND: The cost of medically attended RSV LRI (lower respiratory infection) is critical in determining the economic value of new RSV immunoprophylaxes. However, most studies have focused on intermittent RSV encounters, not the episode of care that captures the entirety of RSV illness. METHODS: We created age- and condition-specific cohorts of children under 5 years of age using MarketScan® data (2015-2019). We contrasted aggregating healthcare costs over RSV-LRTI episodes to ascertaining costs based on RSV-specific encounters only. Economic burden was estimated by multiplying costs per encounter or per episode by their respective incidence rates. RESULTS: Average cost was higher per episode than per encounter regardless of settings (inpatient: $28,586 vs. $18,056 and outpatient/ED: $2099 vs. $407 for infants). Across ages, the economic burden was highest for infants and RSV-LRTI requiring inpatient care, but the burden in outpatient/ED settings was disproportionately higher than costs due to higher incidence rates (for inpatient vs. outpatient episodes: $226,403 vs. $101,269; for inpatient vs. outpatient encounters: $151,878 vs. $38,819 per 1000 infant-years). For high-risk children, cost and burden were up to 3-10 times higher, respectively. CONCLUSIONS: With a comprehensive stratification by settings and risk condition, the encounter- versus episode-based estimates provide a robust range for policymakers' economic appraisal of new RSV immunoprophylaxes.