Health professional retention in underserved areas: findings from the National Health Service Corps Loan Repayment Program participants in the United States, 2019-2021.

Health care provider retention is important for mitigating workforce shortages in underserved areas. The National Health Service Corps (NHSC) provides loan repayment for a two or three-year service commitment from clinicians to work in underserved areas. Prior studies have mixed findings as to what influences clinician retention and have focused mainly on individual-level background characteristics. We used measures of NHSC clinicians' work environment during their service experience, in addition to background characteristics, to identify patterns of experiences, and assess whether these patterns were associated with post-service intentions. We observed that technical assistance and job resources were more influential on clinicians' intentions, compared to individual- or community-level characteristics. Organizations with efficient and supportive work environments may help retain clinicians in underserved areas.

Transitioning an In-Person Survey of Older Adults to Multi-Mode Data Collection.

OBJECTIVES: The first three rounds of the National Social Life, Health, and Aging Project (NSHAP) were in-person. Preparing for Round Four (R4), NSHAP began developing ways to collect complex questionnaire and biomeasure data remotely. R4 was scheduled to begin in 2020, but due to the coronavirus pandemic, NSHAP delayed R4 data collection and instead conducted a study on respondents' experiences during the pandemic, as well as pretests to strengthen NSHAP's remote data collection capability. This paper describes the methodology, results, and lessons learned from these efforts which were undertaken as a bridge between NSHAP's all in-person past and multimode future. METHODS: The Covid-19 Study was a multimode survey of NSHAP respondents to assess the impact of the pandemic. The multimode approach allowed evaluation of the feasibility of using different modes of data collection with older adults. NSHAP adapted its in-person questionnaire for phone and web administration and conducted pretests of the full phone questionnaire and sections of the web questionnaire. The project developed and tested a "BioBox," a kit containing all the supplies and instructions for respondents to self-collect biomeasures remotely. The BioBox was tested through an in-lab and in-home pilot, followed by two larger-scale pretests. RESULTS: The Covid-19 Study and pretests achieved NSHAP respondent participation in remote questionnaire and biomeasure collection, despite being accustomed to fully in-person data collection. DISCUSSION: Our findings and experiences will inform the collection of NSHAP data in future rounds and could inform other panel studies of older adults considering multimode data collection.

Buprenorphine Prescribing and Challenges Faced Among National Health Service Corps Clinicians.

Importance: The National Health Service Corps (NHSC) Loan Repayment Program (LRP) expansion in fiscal year (FY) 2019 intended to improve access to medication for opioid use disorder (MOUD) by adding more clinicians who could prescribe buprenorphine. However, some clinicians still face barriers to prescribing, which may vary between rural and nonrural areas. Objective: To examine the growth in buprenorphine prescribing by NHSC clinicians for Medicaid beneficiaries during the NHSC LRP expansion and describe the challenges to prescribing that persist in rural and nonrural areas. Design, Setting, and Participants: This cross-sectional study analyzed preexpansion and postexpansion Medicaid claims data to evaluate the percentage of prescriptions of buprenorphine filled during FY 2017 through 2021. This study also analyzed challenges and barriers to prescribing MOUD between rural and urban areas, using results from annual surveys conducted with NHSC clinicians and sites from FY 2019 through FY 2021. Exposure: Prescribing of buprenorphine by NHSC clinicians. Main Outcomes and Measures: The main outcomes were the percentage and number of Medicaid beneficiaries with opioid use disorder (OUD) who filled a prescription for buprenorphine before and after the LRP expansion and the challenges NHSC clinicians and sites faced in providing substance use disorder and OUD services. Survey results were analyzed using descriptive statistics. Results: During FYs 2017 through 2021, 7828 NHSC clinicians prescribed buprenorphine (standard LRP: mean [SD] age, 38.1 [8.4] years and 4807 females [78.9%]; expansion LRPs: mean [SD] age, 39.4 [8.1] years and 1307 females [75.0%]). A total of 3297 NHSC clinicians and 4732 NHSC sites responded to at least 1 survey question to the 3 surveys. The overall percentage of Medicaid beneficiaries with OUD who filled a prescription for buprenorphine during the first 2.5 years post expansion increased significantly from 18.9% before to 43.7% after expansion (an increase of 123 422 beneficiaries; P < .001). The percentage more than doubled among beneficiaries living in areas with a high Social Vulnerability Index score (from 17.0% to 36.7%; an increase of 31 964) and among beneficiaries living in rural areas (from 20.8% to 55.7%; an increase of 45 523). However, 773 of 2140 clinicians (36.1%; 95% CI, 33.6%-38.6%) reported a lack of mental health services to complement medication for OUD treatment, and 290 of 1032 clinicians (28.1%; 95% CI, 24.7%-31.7%) reported that they did not prescribe buprenorphine due to a lack of supervision, mentorship, or peer consultation. Conclusions and Relevance: These findings suggest that although the X-waiver requirement has been removed and Substance Abuse and Mental Health Services Administration guidelines encourage all eligible clinicians to screen and offer patients with OUD buprenorphine, as permissible by state law, more trained health care workers and improved care coordination for counseling and referral services are needed to support comprehensive OUD treatment.

Role of the National Health Service Corps in Delivering Substance Use Disorder Treatment in Underserved Communities.

OBJECTIVE: To help address the opioid epidemic, the U.S. Health Resources and Services Administration expanded the National Health Service Corps (NHSC) to include two new loan repayment programs (LRPs)-the Substance Use Disorder LRP and the Rural Community LRP-to supplement the existing standard LRP. In this article, the authors aimed to describe the role of these NHSC programs in addressing workforce shortages and providing substance use disorder treatment, including for opioid use disorder, in underserved areas. METHODS: Administrative data on NHSC clinician locations were merged with county-level data to characterize the communities served by NHSC clinicians. Primary data from surveys and key informant interviews with NHSC site administrators (N=9) and clinicians (N=9) were used to describe changes in NHSC clinician service delivery due to the COVID-19 pandemic. RESULTS: The NHSC LRP expansion increased the number of clinicians providing behavioral health treatment in underserved areas, especially rural areas. A majority of NHSC sites surveyed have increased their provision of substance use disorder treatment since the COVID-19 pandemic began. CONCLUSIONS: This article demonstrates the valuable role of these NHSC programs as resources that policy makers can use to mitigate the challenges of health care workforce shortages and burnout.

Ongoing Refinement and Innovation in the Data Collection Protocols of the Third Round of the National Social Life, Health, and Aging Project.

OBJECTIVES: The third round (R3) of the National Social Life, Health, and Aging Project, a nationally representative, longitudinal survey of community-residing older adults, consisted of 4,777 in-person interviews and 6,100 completed visits to households to identify newly eligible respondents. It revisited respondents from the first rounds (Cohort 1), born in the years 1920 through 1947, and added new respondents (Cohort 2) born in the years 1948 through 1965. Coresidential romantic partners of both cohorts were also eligible. Data collection included in-person questionnaires, up to 11 biomeasures, and a self-administered, postinterview paper questionnaire. METHODS: Questionnaire domains included social network and social support, elder mistreatment, physical health, cognitive function, romantic partners and sexuality, fertility and menopause, mental health, and employment and finances. Biomeasure collection included height, weight, waist circumference, blood pressure and heart rate, timed walk, balance, chair stands, smell, saliva passive drool in a tube (cortisol, dehydroepiandrosterone, estradiol, progesterone, testosterone), dried blood spots (C-reactive protein, Epstein-Barr virus antibodies, high-density lipoprotein cholesterol, hemoglobin, glycosylated hemoglobin [HbA1c], total cholesterol), and accelerometry (sleep patterns and physical activity). A brief questionnaire also collected data on respondents who were deceased or in too poor health to participate. RESULTS: Measures such as response and cooperation rates are provided to evaluate the design and implementation. DISCUSSION: This article describes innovation in the development and implementation of R3, the recruitment of a new cohort of respondents, and fidelity to prior rounds' study design and data collection procedures.

Grandfathered, Grandmothered, And ACA-Compliant Health Plans Have Equivalent Premiums.

Many small employers offer employees health plans that are not fully compliant with Affordable Care Act (ACA) provisions such as covering preventive services without cost sharing. These "grandfathered" and "grandmothered" plans accounted for about 65 percent of enrollment in the small-group market in 2014. Premium costs for these and ACA-compliant plans were equivalent.

Implementation of Telemedicine Consultation to Assess Unplanned Transfers in Rural Long-Term Care Facilities, 2012-2015: A Pilot Study.

INTRODUCTION: Public and private entities in the United States spend billions of dollars each year on potentially avoidable hospitalizations. This is a common occurrence in long-term care (LTC) facilities, especially in rural jurisdictions. This article details the creation of a telemedicine approach to assess residents from rural LTC facilities for potential transfer to hospitals. METHODS: An electronic LTC (eLTC) pilot was conducted in 20 pilot LTC facilities from 2012-2015. Each site underwent technologic assessment and upgrading to ensure that 2-way video communication was possible. A new central "hub" was staffed with advanced practice providers and registered nurses. Long-term care pilot sites were trained and rolled out over 3 years. This article reports development and implementation of the pilot, as well as descriptive statistics associated with provider assessments and averted transfers. RESULTS: Over 3 years, 736 eLTC consultations occurred in pilot sites. One-quarter of consultations occurred between 10 pm and 9 am. Overall, approximately 31% of cases were transferred. This decreased from 54% of cases in 2013 to 17% in 2015. Rural pilot facilities had an average of 23 eLTC consults per site per year. DISCUSSION: Averted transfers represent a dramatic benefit to the residents, as potentially avoidable hospitalizations cause undue stress and allow for nosocomial infections, among other risks. In addition, averting these unnecessary transfers likely saved the taxpayers of the United States over $5 million in admission-related charges to Centers for Medicare and Medicaid Services (511 avoided transfers × $11,000 per average hospitalization from a LTC facility). CONCLUSIONS: Overall, the eLTC pilot showed promise as a proof-of-concept. The pilot's implementation resulted in increasing utilization and promising reductions in unnecessary transfers to emergency departments and hospitalizations.

Collectively bargained health plans: more comprehensive, less cost sharing than employer plans.

National statistics on the cost and provisions of collectively bargained health plans show them to have similar single premiums, but lower family premiums, compared to employer-based plans not subject to collective bargaining. Union members contribute 4 percent and 6 percent of the cost of their premiums for single and family coverage, respectively, versus 18 percent and 29 percent for workers in employer-based plans. Cost sharing in collectively bargained plans is considerably less than in employer-based plans; coverage for prescription drugs is similar.

Continuity and innovation in the data collection protocols of the second Wave of the National Social Life, Health, and Aging Project.

BACKGROUND: The second Wave (W2) of the National Social Life, Health, and Aging Project (NSHAP), a nationally representative, longitudinal survey of older adults now between the ages of 62 and 90, conducted approximately 3,400 interviews. Selected coresidential romantic partners as well as W1 panel nonrespondents were selected for W2. Data collection included in-person questionnaires, up to 15 biomeasures, and a post-interview questionnaire. METHODS: A proxy questionnaire also collected data on respondents that were deceased or in too poor health to participate in W2. Biomeasure collection included height, weight, hip and waist circumference, blood pressure, heart rate, and preventricular contraction, timed walk and chair stands, smell, saliva collection using a Salivette (cortisol), saliva passive drool in a tube (dehydroepiandrosterone, estradiol, progesterone, testosterone), dried blood spots (Epstein-Barr virus antibody titers, C-reactive protein, glycosylated hemoglobin, hemoglobin, cholesterol, high-density lipoprotein), whole blood in a microtainer (cytokines), urine (creatinine, vasopressin, oxytocin), Oragene (genotype), respondent-administered vaginal swabs (bacterial vaginosis,yeast, and vaginal cell cytology), and Actiwatch (sleep patterns and activity). RESULTS: Measures, such as response and cooperation rates, are also provided to evaluate design and implementation. DISCUSSION: This article describes both innovation in the development and implementation of W2 as well as fidelity to W1 study design and data collection procedures.

Small employer perspectives on the Affordable Care Act's premiums, SHOP exchanges, and self-insurance.

Beginning January 1, 2014, small businesses having no more than fifty full-time-equivalent workers will be able to obtain health insurance for their employees through Small Business Health Options Program (SHOP) exchanges in every state. Although the Affordable Care Act intended the exchanges to make the purchasing of insurance more attractive and affordable to small businesses, it is not yet known how they will respond to the exchanges. Based on a telephone survey of 604 randomly selected private firms having 3-50 employees, we found that both firms that offered health coverage and those that did not rated most features of SHOP exchanges highly but were also very price sensitive. More than 92 percent of nonoffering small firms said that if they were to offer coverage, it would be "very" or "somewhat" important to them that premium costs be less than they are today. Eighty percent of offering firms use brokers who commonly perform functions of benefit managers--functions that the SHOP exchanges may assume. Twenty-six percent of firms using brokers reported discussing self-insuring with their brokers. An increase in the number of self-insured small employers could pose a threat to SHOP exchanges and other small-group insurance reforms.

Design and operation of the National Survey of Children's Health, 2007.

OBJECTIVES: This report presents the development, plan, and operation of the 2007 National Survey of Children's Health, a module of the State and Local Area Integrated Telephone Survey, conducted by the Centers for Disease Control and Prevention's National Center for Health Statistics. This survey was designed to produce national and state-specific prevalence estimates for a variety of physical, emotional, and behavioral health indicators and measures of children's experiences with the health care system. The survey also includes questions about the family (for example, parents' health status, stress and coping behaviors, family activities) and about respondents' perceptions of the neighborhoods where their children live. Funding and direction for this survey was provided by the Maternal and Child Health Bureau of the Health Resources and Services Administration. METHODS: A random-digit-dialed sample of households with children under age 18 years was selected from each of the 50 states and the District of Columbia. One child was randomly selected from all children in each identified household to be the subject of the survey. The respondent was a parent or guardian who knew about the child's health and health care. RESULTS: A total of 91,642 interviews were completed from April 2007 to July 2008. Nearly 80% of the interviews were completed in 2007. Interviews were completed in 66.0% of identified households with children. The weighted overall response rate was 46.7%. A data file has been released that contains demographic information on the selected child, substantive health and well-being data for the child and his or her family, and sampling weights. Estimates based on the sampling weights generalize to the noninstitutionalized population of children in each state and nationwide.

Intergenerational Ambivalence: Aging Mothers Whose Adult Daughters are Mentally Ill.

Research on families dealing with mental illness has considered either positive or negative aspects of intergenerational family relationships. The current study extends this work by using intergenerational ambivalence theory to examine aging mothers' contradictory expectations toward adult daughters who are mentally ill. This study focuses on interviews obtained from a sample of 22 mothers aged 52-90 who expressed considerable sociological ambivalence in relation to their grown daughters. Four strategies of managing ambivalence are identified: excusing behaviors, reducing expectations, adjusting help-giving, and confronting. The implications are that practitioners should be aware of intergenerational ambivalence, help aging parents identify their ambivalence management strategies, and assess the extent to which these strategies are adaptive. Future research directions in this area are also discussed.

Design and operation of the National Survey of Adoptive Parents, 2007.

OBJECTIVE: This report presents the development, plan, and operation of the National Survey of Adoptive Parents (NSAP), a module of the State and Local Area Integrated Telephone Survey conducted by the Centers for Disease Control and Prevention's National Center for Health Statistics. NSAP was designed to produce national estimates of the characteristics, health, and well-being of adopted children and their families, the preadoption experiences of the adoptive parents, and their access to and utilization of postadoption supports and services. Funding for the survey was provided by the Office of the Assistant Secretary for Planning and Evaluation and the Administration for Children and Families, both of the Department of Health and Human Services. METHODS: The National Survey of Children's Health, 2007 (NSCH) was a random-digit-dial telephone survey of households with children under age 18 years. In households with more than one child, one child was randomly selected to be the subject of the interview. Children identified as adopted, who did not live with a biological parent and who lived in households where English was spoken, were eligible for the NSAP follow-up interview. The NSAP interview was a call-back scheduled at the end of the NSCH telephone interview. Sampled children included those adopted from other countries, from the U.S. foster care system, and from private domestic sources. Respondents were either the adoptive mother or the adoptive father. RESULTS: A total of 2,089 NSAP interviews were completed from April 2007 to July 2008. The interview completion rate (i.e., cooperation rate) for eligible respondents was 74.4%. The overall response rate, taking into account nonresponse to NSCH, was 34.6%.

Design and operation of the National Survey of Adoptive Parents of Children With Special Health Care Needs, 2008.

OBJECTIVE: This report presents the development, plan, and operation of the National Survey of Adoptive Parents of Children with Special Health Care Needs (NSAP-SN), a module of the State and Local Area Integrated Telephone Survey conducted by the Centers for Disease Control and Prevention's National Center for Health Statistics. The survey was designed to produce national estimates of the characteristics, health, and well-being of adopted children with special health care needs (CSHCN) and their families, the preadoption experiences of the adoptive parents, and their access to and utilization of postadoption services. Funding was provided by the Office of the Assistant Secretary for Planning and Evaluation and the Administration for Children and Families, both of the U.S. Department of Health and Human Services. METHODS: The National Survey of Children with Special Health Care Needs 2005-2006 (NS-CSHCN), a random-digit-dial telephone survey of households with children, included questions that identified whether the sampled child was adopted. Adopted CSHCN under age 18 in 2008 who lived in households where English was spoken were eligible for the NSAP-SN follow-up interview. The NSAP-SN interview was a follow-back telephone call 1 to 3 years after the original NS-CSHCN interview. Sampled children included CSHCN adopted from other countries, from the U.S. foster care system, and from private domestic sources. Respondents were either the adoptive mother or the adoptive father. RESULTS: A total of 1,007 NSAP-SN interviews were completed from February 2008 to July 2008. The interview completion rate (i.e., cooperation rate) for eligible respondents was 67.3%. The overall response rate, taking account of nonresponse to NS-CSHCN, was 37.7%.