Considerations for Opioid Use Disorder Treatment From Policy Makers' Experiences With COVID-19 Policy Flexibilities.

OBJECTIVE: This qualitative study aimed to examine how states implemented COVID-19 public health emergency-related federal policy flexibilities for opioid use disorder treatment from the perspective of state-level behavioral health policy makers. Recommendations are given for applying lessons learned to improve the long-term impact of these flexibilities on opioid use disorder treatment. METHODS: Eleven semistructured interviews were conducted with 13 stakeholders from six state governments, and transcripts were qualitatively coded. Data were analyzed by grouping findings according to state-, institution-, and provider-level barriers and facilitators and were then compared to identify overarching themes. RESULTS: Policy makers expressed positive opinions about the opioid use disorder treatment flexibilities and described benefits regarding treatment access, continuity of care, and quality of care. No interviewees reported evidence of increased adverse events associated with the relaxed medication protocols. Challenges to state-level implementation included gaps in the federal flexibilities, competing state policies, facility and provider liability concerns, and persistent systemic stigma. CONCLUSIONS: As the federal government considers permanent adoption of COVID-19-related flexibilities regarding opioid use disorder treatment policies, the lessons learned from this study are crucial to consider in order to avoid continuing challenges with policy implementation and to effectively remove opioid use disorder treatment barriers.

Rural Hospitals Experienced More Patient Volume Variability Than Urban Hospitals During The COVID-19 Pandemic, 2020-21.

Fluctuations in patient volume during the COVID-19 pandemic may have been particularly concerning for rural hospitals. We examined hospital discharge data from the Healthcare Cost and Utilization Project State Inpatient Databases to compare data from the COVID-19 pandemic period (March 8, 2020-December 31, 2021) with data from the prepandemic period (January 1, 2017-March 7, 2020). Changes in average daily medical volume at rural hospitals showed a dose-response relationship with community COVID-19 burden, ranging from a 13.2 percent decrease in patient volume in periods of low transmission to a 16.5 percent increase in volume in periods of high transmission. Overall, about 35 percent of rural hospitals experienced fluctuations exceeding 20 percent (in either direction) in average daily total volume, in contrast to only 13 percent of urban hospitals experiencing similar magnitudes of changes. Rural hospitals with a large change in average daily volume were more likely to be smaller, government-owned, and critical access hospitals and to have significantly lower operating margins. Our findings suggest that rural hospitals may have been more vulnerable operationally and financially to volume shifts during the pandemic, which warrants attention because of the potential impact on these hospitals' long-term sustainability.

Medicare Advantage in rural areas: implications for hospital sustainability.

OBJECTIVES: A growing number of Medicare beneficiaries in rural areas are enrolled in Medicare Advantage plans, which negotiate hospital reimbursement. This study examined the association between Medicare Advantage penetration levels in rural areas and hospital financial distress and closure. STUDY DESIGN: This retrospective cohort study followed rural general acute care hospitals open in 2008 through 2019 or until closure using Healthcare Cost and Utilization Project State Inpatient Databases for 14 states. METHODS: The primary independent variables were the percentage of Medicare Advantage stays out of total Medicare stays at the hospital and the percentage of Medicare Advantage beneficiaries out of total beneficiaries in the hospital's county. Financial distress was defined using the Altman Z score, where values less than or equal to 1.1 indicate financial distress and values greater than 2.8 indicate stability. The Z score was examined as a continuous outcome in hospital and county fixed-effects models. Risk of closure was examined using Cox proportional hazard models adjusted for hospital and market factors. RESULTS: Rural hospital Medicare Advantage penetration grew from 6.5% in 2008 to 20.6% in 2019. A 1-percentage point increase in hospital penetration was associated with an increase in financial stability of 0.04 units on the Altman Z score (95% CI, 0.00-0.08; P = .03) and a 4% reduction in risk of closure (HR, 0.96; 95% CI, 0.92-1.00; P = .04). Results were consistent when measuring Medicare Advantage penetration at the county level. CONCLUSIONS: Our findings counter the notion that Medicare Advantage plans financially hurt rural hospitals because they pay less generously than traditional Medicare.

Medications for Opioid Use Disorder During the Prenatal Period and Infant Outcomes.

This cross-sectional study explores the association between mothers' receipt of opioid use disorder treatment during pregnancy and their infants' health services use in the first year of life.

Risk of Closure Among Independent and Multihospital-Affiliated Rural Hospitals.

Importance: The increase in rural hospital closures has strained access to inpatient care in rural communities. It is important to understand the association between hospital system affiliation and access to care in these communities to inform policy on this issue. Objective: To examine the association between affiliation and rural hospital closure. Design Setting and Participants: This cohort study used survival models with a time-dependent variable for affiliation vs independent status to assess risk of closure among a national cohort of US rural hospitals from January 2007 through December 2019. Data analysis was conducted from March to October 2021. Hospital affiliations were identified from the American Hospital Association Annual Survey and Irving Levin Associates and closures from the University of North Carolina Sheps Center (Chapel Hill). Additional covariates came from the Healthcare Cost and Utilization Project State Inpatient Databases and other national sources. Exposures: Affiliation with another hospital or multihospital health system. Main Outcomes and Measures: Closure was the main outcome. The models included hospital, market, and utilization characteristics and were stratified by financial distress in 2007. Results: Among 2237 rural hospitals operating in 2007, 140 (6.3%) had closed by 2019. The proportion of rural hospitals that were independent decreased from 68.9% in 2007 to 47.0% in 2019; the proportion that were affiliated increased from 31.1% to 46.7%. Among financially distressed hospitals in 2007, affiliation was associated with lower risk of closure compared with being independent (adjusted hazard ratio [aHR], 0.49; 95% CI, 0.26-0.92). Conversely, among hospitals that were financially stable in 2007, affiliation was associated with higher risk of closure compared with being independent (aHR, 2.36; 95% CI, 1.20-4.62). For-profit ownership was also strongly associated with closure for hospitals that were financially stable in 2007 (aHR, 4.08; 95% CI, 1.86-8.97). Conclusions and Relevance: The results of this cohort study suggest that affiliations may be associated with lower risk of closure for some rural hospitals in financial distress. However, among initially financially stable hospitals, an increased risk of closure for hospitals associated with affiliation and proprietary ownership raises concerns about the association of affiliation with closures in some circumstances. Policy interventions to stabilize inpatient care in rural areas should account for these findings.

Access To Obstetric, Behavioral Health, And Surgical Inpatient Services After Hospital Mergers In Rural Areas.

Despite rural hospitals' central role in their communities, they are increasingly in financial distress and may merge with other hospitals or health systems, potentially reducing service lines that are less profitable or duplicative of services that the acquirer also offers. Using hospital discharge data from thirty-two Healthcare Cost and Utilization Project State Inpatient Databases from the period 2007-18, we examined the influence of rural hospital mergers on changes to inpatient service lines at hospitals and within their catchment areas. We found that merged hospitals were more likely than independent hospitals to eliminate maternal/neonatal and surgical care. Whereas the number of mental/substance use disorder-related stays decreased or remained stable at merged hospitals and within their catchment areas, it increased for unaffiliated hospitals and their catchment areas, indicating a potential unmet need in the communities of rural hospitals postmerger. Although a merger could salvage a hospital's sustainability, it also could reduce service lines and responsiveness to community needs.

Cost Offsets of Treatment for Serious Mental Illness and Substance Use Disorder.

OBJECTIVE: The authors examined whether timely treatment for serious mental illness and substance use disorder reduces overall health care costs in a 3-year period. METHODS: Claims data from the IBM MarketScan Research Databases (2010-2017) were analyzed. The population studied included 2,997 Medicaid enrollees and 35,805 commercial insurance enrollees ages 18-64 years with an index event for a serious mental illness and 2,315 Medicaid enrollees and 28,419 commercial insurance enrollees with an index event for a substance use disorder. Health care costs in the 3 years after an index event were calculated for enrollees who received care that met a minimum threshold for treatment and for those who did not receive such care. The Toolkit for Weighting and Analysis of Nonequivalent Groups was used to control for statistically significant differences in pretreatment characteristics between the groups. RESULTS: All health care spending for enrollees who were engaged in behavioral health treatment for substance use disorder or a serious mental illness increased from year 0 to year 1 but decreased faster than the spending of enrollees who were not engaged in treatment, with larger trends for those engaged in substance use disorder treatment. Expenses for inpatient and emergency department care decreased over the 3 follow-up years; however, spending on outpatient services was significantly higher in all 3 follow-up years for those engaged in treatment. CONCLUSIONS: Health care delivery and payment models that improve access to behavioral health treatment may reduce emergency department, inpatient, and overall health care costs for particular subpopulations.

Lean Management and Hospital Performance: Adoption vs. Implementation.

BACKGROUND: The Lean management system is being adopted and implemented by an increasing number of US hospitals. Yet few studies have considered the impact of Lean on hospitalwide performance. METHODS: A multivariate analysis was performed of the 2017 National Survey of Lean/Transformational Performance Improvement in Hospitals and 2018 publicly available data from the Agency for Healthcare Research and Quality and the Center for Medicare & Medicaid Services on 10 quality/appropriateness of care, cost, and patient experience measures. RESULTS: Hospital adoption of Lean was associated with higher Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) patient experience scores (b = 3.35, p < 0.0001) on a scale of 100-300 but none of the other 9 performance measures. The degree of Lean implementation measured by the number of units throughout the hospital using Lean was associated with lower adjusted inpatient expense per admission (b = -38.67; p < 0.001), lower 30-day unplanned readmission rate (b = -0.01, p < 0.007), a score above the national average on appropriate use of imaging-a measure of low-value care (odds ratio = 1.04, p < 0.042), and higher HCAHPS patient experience scores (b = 0.12, p < 0.012). The degree of Lean implementation was not associated with any of the other 6 performance measures. CONCLUSION: Lean is an organizationwide sociotechnical performance improvement system. As such, the actual degree of implementation throughout the organization as opposed to mere adoption is, based on the present findings, more likely to be associated with positive hospital performance on at least some measures.

Adverse events among adult Medicaid enrollees with opioid use disorder and co-occurring substance use disorders.

BACKGROUND: It is common for adults with opioid use disorder (OUD) to misuse additional substances, and these individuals may be particularly at risk for adverse events, including mortality. Less is known about how continued receipt of prescription opioids or risk of adverse events (e.g., suicidality, overdose, poisoning) differs for people with co-occurring OUD and additional substance use disorders (SUDs). METHODS: We conducted a retrospective study using IBM® MarketScan® Multi-State Medicaid Database enrollment/claims data. We used logistic regression to measure the association between sample characteristics and our dependent variables. The sample consisted of non-Medicare-eligible adults aged 18-64 years who were continuously enrolled in Medicaid in 2016-2017 with an OUD diagnosis on at least one claim in 2016. RESULTS: Adults with OUD and a co-occurring SUD were more likely than adults with OUD only to have an opioid-related poisoning event (odds ratio [OR] = 1.488, p = .0052), all-cause poisoning (OR = 1.756, p < .0001), or suicidal ideation (OR = 1.796, p < .0001) but not to receive ongoing opioid prescriptions (OR = 0.973, p = .1626). Adverse events varied by OUD-SUD combination. For example, adults with OUD and cocaine use disorder had the highest odds of all-cause (OR = 2.393, p < .0001) or opioid-related (OR = 1.890, p = .0027) poisoning among those with a drug-specific diagnosis and were most likely to be diagnosed with suicidal ideation (OR = 2.465, p < .0001). CONCLUSIONS: This study provides evidence that adults with OUD and a co-occurring additional SUD have increased risk for several adverse events. Multisubstance use should be screened for and identified to determine the most appropriate course of treatment.

Adoption of Lean management and hospital performance: Results from a national survey.

BACKGROUND: Despite being adopted by a large number of hospitals, the relationship between Lean management and hospital performance is mixed and not well understood. PURPOSE: We examined the relationships between Lean and hospital financial performance, patient outcomes, and patient satisfaction in a large national sample of hospitals, controlling for relevant organizational and market factors. METHODOLOGY/APPROACH: A mixed effects linear regression analysis was performed to assess the relationships between adoption of Lean and 10 measures of hospital performance using data from 1,152 hospitals that responded to the 2017 National Survey of Lean/Transformational Performance Improvement in Hospitals. Hospital performance, organizational, and market data over the period 2011-2015 come from the 2015 American Hospital Association Annual Hospital Survey and the respective annual Centers for Medicare & Medicaid Services (CMS) Medicare Cost Report, CMS Hospital Compare, CMS MEDPAR, and the CMS Hospital Service Area File. RESULTS: Lean adoption was significantly associated at alpha < .05, with lower Medicare spending per beneficiary (b = -.005, p = .027). None of the other nine associations were statistically significant, although eight of them were in the predicted direction. CONCLUSION: Lean adoption is not associated with most measures of hospital performance. It is likely Lean implementation varies greatly across hospitals. Future research should examine the relationships among the various dimensions of Lean implementation and performance. PRACTICE IMPLICATIONS: If Lean management is to contribute to hospital performance improvement, leaders must be highly cognizant of what "adoption of Lean" actually means in their hospital. Although limited, single-unit Lean initiatives in an emergency room or other patient care unit may improve performance on some unit-specific measures, improvement on hospital-wide measures of performance requires a broad, sustained commitment to the implementation of Lean practices and tools.