It's time for the NIH to formally designate people with disabilities as a US health disparity population.

This commentary discusses the implications of the report and recommendations of the Working Group on Diversity's Subgroup on Individuals with Disabilities, recently endorsed by the full Advisory Committee to the Director (ACD) of the National Institutes of Health (NIH). We suggest that one of these recommendations, the formal designation of people with disabilities as a US health disparity population, can be enacted immediately, which would spur new federal investment in disability-based disparities research.

Factors associated with frequent or daily use of prescription opioids among adults with chronic pain in the United States.

OBJECTIVES: We aimed to estimate utilization rates of prescription opioids among adults with chronic pain in the United States (US) and identify factors associated with the frequent or daily use of prescription opioids. METHODS: This was a case-control analysis of the 2019 National Health Interview Survey of adults. RESULTS: Over 50.2 million adults in the US reported chronic pain in the past 3 months, but only 10.5% of this group said they used prescription opioids frequently or daily to manage their pain. Adults with chronic pain were significantly more likely to use opioids if they had incomes below the federal poverty level (15.7%), relied on public health insurance (14.8%), had been hospitalized in the past year (17.8%), or rated their health as fair or poor (18.4%). The highest rates of opioid use were reported among adults with severe (24.4%) or moderate disability (18.9%). CONCLUSIONS: Approximately 5.3 million adults use prescription opioids frequently or daily to manage chronic pain. These individuals should receive regular clinical assistance to manage their pain, including medication management and, when appropriate, referral to evidence-based treatment programs for opioid use disorder.

Responding to the Needs of People with Disabilities in the COVID-19 Pandemic: Community Perspectives from Centers for Independent Living.

Centers for Independent Living (CILs) are federally funded, community-based organizations designed and operated by people with disabilities that provide individual and systems advocacy, peer support, information and referral, independent living skills training, and transition services throughout the U.S. and its territories. Centers for Independent Living therefore offer a rich and detailed perspective on the needs of people with disabilities during the COVID-19 pandemic. In this brief report, we summarize COVID-19-related issues raised by 144 CIL administrators and staff in a national survey conducted in April and May 2020 and discuss their research and policy implications. Respondents voiced concerns about health and safety, long-term supportive services, social isolation, and economic insecurity. In the words of one center director, "The pandemic has pulled back the curtain on the depth of need in our local disability community."

Disability stories: personal perspectives of people with disabilities on navigating the U.S. health system.

Americans with disabilities and chronic illness or injury tend to be in poorer health, use more health services, and pay more for healthcare than those without disabilities. Consequently, their lives can be profoundly affected by federal and state health policies. The concerns of this population do not figure prominently in national health policy discourse and related public health and health services research efforts. This study sought to give voice to the lived experiences of people with disabilities as they navigate a fragmented U.S. healthcare system. We interviewed 30 adults who self-identified as having a disability and spoke or otherwise communicated in the English language. Directed content analysis was used to examine words and phrases in professionally transcribed documents by experienced qualitative researchers. We report and discuss four themes from the perspective of the participant, presented in thematic statements, related to vocation, finances, stressors, and advocacy.

Unfilled Prescriptions of Medicare Beneficiaries: Prevalence, Reasons, and Types of Medicines Prescribed.

BACKGROUND: Despite the proven efficacy of prescription regimens in reducing disease symptoms and preventing or minimizing complications, poor medication adherence remains a significant public health problem. Medicare beneficiaries have high rates of chronic illness and prescription medication use, making this population particularly vulnerable to nonadherence. Failure to fill prescribed medication is a key component of nonadherence. OBJECTIVES: To (1) determine the rates of self-reported failure to fill at least 1 prescription among a sample of Medicare beneficiaries in 2004, (2) identify the reasons for not filling prescribed medication, (3) examine the characteristics of Medicare beneficiaries who failed to fill their prescription(s), and (4) identify the types of medications that were not obtained. METHODS: The study is a secondary analysis of the 2004 Medicare Current Beneficiary Survey (MCBS), an ongoing national panel survey conducted by the Centers for Medicare & Medicaid Services (CMS). Medicare beneficiaries living in the community (N = 14,464) were asked: "During the current year [2004], were there any medicines prescribed for you that you did not get (please include refills of earlier prescriptions as well as prescriptions that were written or phoned in by a doctor)?" Those who responded "yes" to this question (n = 664) were asked to identify the specific medication(s) not obtained. Rates of failure to fill were compared by demographic and income categories and for respondents with versus without self-reported chronic conditions, identified by asking respondents if they had ever been told by a doctor that they had the condition. Weighted population estimates for nonadherence were calculated using Professional Software for SUrvey DAta ANalysis for Multi-stage Sample Designs (SUDAAN) to account for the MCBS multistage stratified cluster sampling process. Unweighted counts of the prescriptions not filled by therapeutic class were calculated using Statistical Analysis Software (SAS). RESULTS: In 2004, an estimated 1.6 million Medicare beneficiaries (4.4%) failed to fill or refill 1 or more prescriptions. The most common reasons cited for failure to fill were: "thought it would cost too much" (55.5%), followed by "medicine not covered by insurance" (20.2%), "didn't think medicine was necessary for the condition" (18.0%), and "was afraid of medicine reactions/contraindications" (11.8%). Rates of failure to fill were significantly higher among Medicare beneficiaries aged 18 to 64 years eligible through Social Security Disability Insurance (10.4%) than among beneficiaries aged 65 years or older (3.3%, P < 0.001). Rates were slightly higher for women than for men (5.0 vs. 3.6%, P = 0.001), for nonwhite than for white respondents (5.5% vs. 4.2%, P = 0.010), and for dually eligible Medicaid beneficiaries than for those who did not have Medicaid coverage (6.3% vs. 4.0% P = 0.001). Failure-to-fill rates were significantly higher among beneficiaries with psychiatric conditions (8.0%, P < 0.001); arthritis (5.2%, P < 0.001); cardiovascular disease (5.2%, P = 0.003); and emphysema, asthma, or chronic obstructive pulmonary disease (6.6%, P < 0.001) than among respondents who did not report those conditions, and the rate for respondents who reported no chronic conditions was 2.5%. Rates were higher for those with more self-reported chronic conditions (3.2%, 4.0%, 4.3%, and 5.9% for those with 1, 2, 3, and 4 or more conditions, respectively, P < 0.001). Among the prescriptions not filled (993 prescriptions indentified by 664 respondents), central nervous system agents, including nonsteroidal anti-inflammatory drugs, were most frequently identified (23.6%, n = 234), followed by cardiovascular agents (18.3%, n = 182) and endocrine/metabolic agents (6.5%, n = 65). Of the reported unfilled prescriptions, 8.1% were for antihyperlipidemic agents, 5.4% were for antidepressant drugs, 4.6% were for antibiotics, and 29.9% were for unidentified therapy classes. CONCLUSION: Most Medicare beneficiaries fill their prescriptions, but some subpopulations are at significantly higher risk for nonadherence associated with unfilled prescriptions, including working-age beneficiaries, dual-eligible beneficiaries, and beneficiaries with multiple chronic conditions. Self-reported unfilled prescriptions included critical medications for treatment of acute and chronic disease, including antihyperlipidemic agents, antidepressants, and antibiotics. DISCLOSURES: This study was funded by the U.S. Department of Education's National Institute on Disability and Rehabilitation Research, Field Initiated Research Grant H133G070055. However, the analysis and the interpretation of these findings do not necessarily represent the policy of the Department of Education and are not endorsed by the federal government. All authors contributed approximately equally to the study concept and design. Tuleu performed the majority of the data collection, with assistance from Kennedy. Kennedy interpreted the data, with assistance from Tuleu and Mackay. Kennedy and Mackay wrote the majority of the manuscript, with assistance from Tuleu. Kennedy made the majority of the changes in revision of the manuscript.

Disparities in Insurance Coverage, Health Services Use, and Access Following Implementation of the Affordable Care Act: A Comparison of Disabled and Nondisabled Working-Age Adults.

The objective of this study was to assess trends in health insurance coverage, health service utilization, and health care access among working-age adults with and without disabilities before and after full implementation of the Affordable Care Act (ACA), and to identify current disability-based disparities following full implementation of the ACA. The ACA was expected to have a disproportionate impact on working-age adults with disabilities, because of their high health care usage as well as their previously limited insurance options. However, most published research on this population does not systematically look at effects before and after full implementation of the ACA. As the US Congress considers new health policy reforms, current and accurate data on this vulnerable population are essential. Weighted estimates, trend analyses and analytic models were conducted using the 1998-2016 National Health Interview Surveys (NHIS) and the 2014 Medical Expenditure Panel Survey. Compared with working-age adults without disabilities, those with disabilities are less likely to work, more likely to earn below the federal poverty level, and more likely to use public insurance. Average health costs for this population are 3 to 7 times higher, and access problems are far more common. Repeal of key features of the ACA, like Medicaid expansion and marketplace subsidies, would likely diminish health care access for working-age adults with disabilities.

Medication Costs and Adherence of Treatment Before and After the Affordable Care Act: 1999-2015.

To examine national changes in rates of cost-related prescription nonadherence (CRN) by age group, we used data from the 1999-2015 Sample Adult and Sample Child National Health Interview Surveys (n = 768 781). In a logistic regression analysis of 2015 data, we identified subgroups at risk for cost-related nonadherence. The proportion of all Americans who did not fill a prescription in the previous 12 months because they could not afford it grew from 1999 to 2009, peaking at 8.3% at the height of the Great Recession and dropping to 5.2% by 2015. CRN among seniors, however, peaked in 2004 at 5.4% and dropped to 3.6% after implementation of Medicare Part D in 2006. CRN is responsive to improved access related to implementation of Medicare Part D and the Affordable Care Act.

After CLASS--Is a voluntary public insurance program a realistic way to meet the long-term support and service needs of adults with disabilities?

BACKGROUND: The CLASS Act, which was part of the Affordable Care Act of 2010, established a voluntary personal assistance services (PAS) insurance program. However, concerns about enrollment and adverse selection led to repeal of the CLASS Act in 2013. OBJECTIVES: To estimate the number of middle-aged adults interested in purchasing PAS insurance, the sociodemographic, socioeconomic and disability attributes of this population, and the maximum monthly premium they would be willing to pay for such coverage. METHODS: A total of 13,384 adults aged 40-65 answered questions about their interest in PAS insurance in the 2011 Sample Adult National Health Interview Survey. We applied survey weights for the U.S. population and conducted logistic regression analyses to identify personal factors associated with interest in paying for the CLASS program. RESULTS: An estimated 25.8 million adults aged 40-65 (26.7%) said they would be interested in paying for a public insurance program to cover PAS benefits. However, interest in PAS insurance varied by age, race, ethnicity, region, income, disability status, and family experience with ADL assistance. Only 1.6 million adults aged 40-65 (1.8%) said they would be willing to pay $100 per month or more for coverage. CONCLUSIONS: While more than a quarter of the middle-aged adult population said they were interested in PAS insurance, actual participation would be highly dependent on premium rates. The current lack of publicly subsidized insurance for long-term care and personal assistance services remains a serious gap in the disability service system.

Alternative Therapies as a Substitute for Costly Prescription Medications: Results from the 2011 National Health Interview Survey.

PURPOSE: Some researchers have suggested that the popularity of complementary and alternative medicine (CAM) in the United States is due, in part, to the growing cost of conventional medical care. The 2011 National Health Interview Survey is the first population survey that directly asks respondents if they have substituted alternative therapies for prescription medications. The purpose of this study was to estimate the adult prevalence of CAM substitution and to identify factors associated with cost-related CAM use. METHODS: The sample adult core component of the 2011 National Health Interview Survey (N = 33,014) included a number of questions about prescription medication access and use, including "in the past 12 months, did you use alternative therapies to save money?" We used the Behavioral Model of Health Services Use to identify factors associated with the use of alternative therapies among respondents. Multivariate logistic regression models were used to evaluate factors associated with cost-related CAM use. FINDINGS: An estimated 12.3 million adults (5.4% of the population) used alternative therapies to save money in 2011. Women, middle-aged (31-50 years) adults, and residents of the western United States were more likely to engage in CAM substitution, as were smokers, those with activity limitations, and those in fair or poor health. The highest rates of CAM substitution were reported by uninsured adults (11.9%). IMPLICATIONS: A sizable number of adults in the United States use alternative therapies because they are cheaper than prescription medications. The health risks of such CAM substitution can be serious, and the phenomenon merits further investigation.

Prevalence of persistent pain in the U.S. adult population: new data from the 2010 national health interview survey.

UNLABELLED: Published adult prevalence estimates of chronic pain in the United States vary significantly. A more consistent pain measure is needed to assess unmet need for pain management in the general population. In this study, secondary analyses of the 2010 Quality of Life Supplement of the National Health Interview Survey are used to calculate the point prevalence of "persistent pain," which we defined as constant or frequent pain persisting for at least 3 months. Rates of persistent pain are also calculated by risk group, chronic condition, and disability status. Findings show that about 19.0% of adults in the United States report persistent pain. Rates of persistent pain are higher among women, adults aged 60 to 69, adults who rate their health as fair or poor, adults who are overweight or obese, and those who were hospitalized 1 or more times in the preceding year. Most adults who report conditions such as arthritis, carpal tunnel syndrome, or back or joint pain do not describe their pain as "persistent." Of the estimated 39.4 million adults who report persistent pain, 67.2% say their pain is "constantly present," and 50.5% say their pain is sometimes "unbearable and excruciating." PERSPECTIVE: Persistent pain, defined as self-reported pain "every day" or "most days" in the preceding 3 months, is a useful way to characterize health-related quality of life in the general population, and policy makers should consider including this core measure in ongoing health surveys like the National Health Interview Survey and the Medical Expenditure Panel Survey, the authors conclude.

Trend and pattern of herb and supplement use in the United States: results from the 2002, 2007, and 2012 national health interview surveys.

Background. In 1990s, complementary and alternative medicine (CAM), including use of herbs and supplements, gained popularity in the United States. However, more recent surveys suggest that demand for herbs and supplements has stabilized. Objective. This study examined the prevalence, patterns, and changes in herb and supplement use among the US adults, using the 2002, 2007, and 2012 National Health Interview Surveys (NHIS). Methods. Weighted population estimates were derived from three complementary and alternative medicine supplements to the NHIS. Prevalence rates for herb and supplement use were compared, using Wald chi-square tests to measure changes between years. Results. An estimated 40.6 million US adults reported herb and supplement use in 2012. However, the rate of herb and supplement use dropped from 18.9% in 2002 to 17.9% in 2007 and 2012 (P < 0.05). This decline in use was more pronounced among women, racial or ethnic minorities, and adults with low incomes. Conclusion. Herb and supplements use remains common in the USA, but adult use rates are on the decline. It is still important for health care providers to ask patients about herb and supplement use.

The prevalence of herb and dietary supplement use among children and adolescents in the United States: Results from the 2007 National Health Interview Survey.

OBJECTIVE: The purpose of this study is to examine the national prevalence of herb and dietary supplement usage among children and adolescents age 4-17 in the United States, and to identify population factors associated with usage. METHODS: Weighted population estimates are derived from the 2007 National Health Interview Child Complementary and Alternative Medicine Supplement (sample n=9417). Wald chi-square tests are used to compare factors associated with herb and dietary supplement use. RESULTS: An estimated 2.9 million children and adolescents used herbs or dietary supplements in 2007. Pediatric herb and supplement use was more common among adolescents and non-Hispanic whites, and positively associated with parental education and household income. Children with activity limitations due to chronic health conditions, long-term prescription use, or relatively heavy use of physician services were also more likely to use herbal supplements. Echinacea and fish oil were most commonly used herbs and supplements. CONCLUSIONS: Children in the US appear to use herbs or dietary supplements at a much lower rate than adults. This analysis shows a pattern of moderate and appropriate herb and supplement use in the pediatric population.

Return to work: a critical aspect of care coordination for younger dual eligibles.

BACKGROUND: Annual health care costs for dual eligibles now top $300 billion. Many dual eligibles are under age 65 and their needs differ significantly from retired elderly dual eligibles. For younger dual eligibles, successful return to work is an important objective for coordinated care. OBJECTIVES: To assess relative rates of dual eligibility by age group and program enrollment (SSDI or OASI), and to identify the prevalence among these subgroups of factors associated with return to work. METHODS: Population estimates and logistic regression analysis of the 2010 Medicare Current Beneficiary Survey (MCBS). RESULTS: Although they make up only 16% of the total Medicare beneficiary population, disabled workers under age 65 constitute 42% of all dual eligibles. SSDI beneficiaries under age 45 have 20 times greater odds of receiving Medicaid benefits compared to retirees (AOR = 19.8, 95% CI = 16.2-24.2). The youngest dual eligible adults are more likely to work, have fewer chronic conditions, and report better health status than other dual eligibles. However, they are more likely to report problems with obtaining health care and be dissatisfied with the quality of the care they receive. CONCLUSIONS: Dual eligible workers with disabilities are an important target population for coordinated services because of their high lifetime program costs - many will receive SSDI, SSI, Medicare, and Medicaid benefits for decades. Return to work and continued employment are important policy objectives for younger dual eligibles and should provide the greatest return in terms of reduced dependence on federal disability programs.

Disparities in unmet need for mental health services in the United States, 1997-2010.

OBJECTIVES: This study estimated unmet need for mental health services, identified population risk factors related to unmet need, and established baseline data to assess the impact of the Affordable Care Act (ACA) and the Mental Health Parity and Addiction Equity Act. METHODS: National Health Interview Survey data (1997-2010) were analyzed. RESULTS: Unmet need increased from 4.3 million in 1997 to 7.2 million in 2010. Rates in 2010 were about five times higher for uninsured than for privately insured persons. In a multivariate logistic model, likelihood was higher among children (age two to 17), working-age adults (age 18-64), women, uninsured persons, persons with low incomes, in fair or poor health, and with chronic conditions. CONCLUSIONS: Unmet need is widespread, particularly among the uninsured. Expansion of coverage under the ACA, in conjunction with federal parity, should improve access, but ongoing monitoring of access is a research and policy priority.

Implementation of paperless credentialing in a multi-state managed care organization.

OBJECTIVES: To evaluate the impact of paperless provider credentialing in a multi-state managed care organization. STUDY DESIGN: Implementation took place from June to October of 2009. A total of 6220 providers were credentialed during this study period and selected for analysis. We used an interrupted time-series design, centered the data on implementation, and then compared efficiency rates for the 14 weeks before implementation of paperless credentialing to efficiency rates for the 14 weeks after implementation. LIMITATIONS: The absence of a control group and a relatively short observation period are potential threats to validity. METHODS: The main unit of analysis was the provider credentialing file. We compared quality review pass rates, processing time (in days), and processing cost per file before and after paperless credentialing implementation. RESULTS: The percentage of files passing quality review increased from 83% to 92%. The turnaround time for the credentialing process dropped from 53 calendar days to 36 calendar days. CONCLUSIONS: Implementation of electronic credentialing appears to significantly improve processing efficiency. Indeed, credentialing seems to be a particularly promising area for adoption of electronic records in an administrative setting.

Changes in herb and dietary supplement use in the U.S. adult population: a comparison of the 2002 and 2007 National Health Interview Surveys.

BACKGROUND: Past national surveys indicate that use of herbs and dietary supplements rose rapidly in the United States during the 1990s and early 2000s. Additional research is needed to determine whether this growth rate and associated patterns of use have persisted over time. OBJECTIVES: The objectives of this study were: (1) to assess population and subpopulation changes in rates of herb and supplement use; and (2) to assess changes in rates of disclosure of herb and supplement use to conventional medical providers. METHODS: This study used data from the 2002 (n = 30,427) and 2007 (n = 22,657) Adult Complementary and Alternative Medicine File to the National Health Interview Survey (NHIS). Weighted group and subgroup comparisons used the Wald χ(2) tests to compare differences in herb and supplement use between 2002 and 2007. RESULTS: The number of adults in the United States that ever used herbs or supplements grew slightly, from 50.6 million in 2002 to 55.1 million in 2007. However, the proportion of adults who reported use of herbs or supplements in the past 12 months dropped significantly: from 18.9% in 2002 to 17.9% in 2007 (P < 0.05). Subpopulation comparisons revealed that younger adults were less likely to use herbs and supplements in 2007 (17.6%) than in 2002 (20.0%), whereas older adults (ie, those aged ≥65 years) were more likely to do so (19.5% in 2007 vs. 13.2% in 2002). Racial and ethnic minorities also reported a significant decline in recent use. The proportion of respondents that disclosed herb or supplement use to their physician or another conventional medical professional rose, from 33.4% in 2002 to 45.4% in 2007. However, <1% of recent herb and supplement users disclosed this use to their pharmacist. Limitations of this research are that the 2 national data sets were not directly comparable and that questionnaires in the 2 surveys assessed were not identical. CONCLUSIONS: Herbal preparations and dietary supplements remain popular in the United States, but the user population and patterns of use are changing. Ongoing surveillance of this health behavior is a public health priority.

Medicare prescription drug plan coverage of pharmacotherapies for opioid and alcohol dependence in WA.

OBJECTIVES: Pharmacotherapeutic treatments for drug addiction offer new options, but only if they are affordable for patients. The objective of this study is to assess the current availability and cost of five common antiaddiction medications in the largest federal medication insurance program in the US, Medicare Part D. METHODS: In early 2010, we collected coverage and cost data from 41 Medicare Part D prescription drug plans (PDPs) and 45 Medicare Advantage Plans (MAPs) in Washington State. RESULTS: The great majority of Medicare plans (82-100%) covered common pharmacotherapeutic treatments for drug addiction. These Medicare plans typically placed patent protected medications on their highest formulary tiers, leading to relatively high patient co-payments during the initial Part D coverage period. For example, median monthly co-payments for buprenorphine (Suboxone®) were about $46 for PDPs, and about $56 for MAPs. CONCLUSION: While Medicare prescription plans usually cover pharmacotherapeutic treatments for drug addiction, high co-payments can limit access. For example, beneficiaries without supplemental coverage who use Vivitrol® would exceed their initial coverage cap in 7-8 months, reaching the "doughnut hole" in their Part D coverage and becoming responsible for the full cost of the medication (over $900 per month). The 2010 Patient Protection and Affordable Care Act will gradually eliminate this coverage gap, and loss of patent protection for other antiaddiction medications (Suboxone® and Campral®) should also drive down patient costs, improving access and compliance.

Prescription drug accessibility and affordability in the United States and abroad.

This issue brief contrasts prescription drug access, affordability, and costs in the United States with six other high-income countries, drawing from Commonwealth Fund survey data of patient experiences as well as international spending and pricing data. The analysis reveals that Americans, particularly the relatively young and healthy, are more likely to use prescription drugs than are residents of Australia, Canada, Germany, the Netherlands, New Zealand, and the United Kingdom, but they also experience more financial barriers in accessing medications and spend more out-of-pocket for prescriptions. In the U.S., there are also larger income-related inequities in pharmaceutical use. Despite access barriers and disparities, spending per person in the U.S. is far higher, likely the result of paying higher prices for similar medications and using a more expensive mix of drugs. The authors say that value-based benefit designs, reference pricing, and group purchasing could reduce financial barriers and keep down pharmaceutical spending.