Financial Interventions to Improve Screening in Primary Care: A Systematic Review.

INTRODUCTION: Although health screenings offer timely detection of health conditions and enable early intervention, adoption is often poor. How might financial interventions create the necessary incentives and resources to improve screening in primary care settings? This systematic review aimed to answer this question. METHODS: Peer-reviewed studies published between 2000 and 2023 were identified and categorized by the level of intervention (practice or individual) and type of intervention, specifically alternative payment models (APMs), fee-for-service (FFS), capitation, and capital investments. Outcomes included frequency of screening, performance/quality of care (e.g., patient satisfaction, health outcomes), and workflow changes (e.g., visit length, staffing). RESULTS: Of 51 included studies, a majority focused on practice-level interventions (n=32), used APMs (n=41) that involved payments for achieving key performance indicators (KPIs; n=31) and were of low or very low strength of evidence based on GRADE criteria (n=42). Studies often included screenings for cancer (n=32), diabetes care (n=18), and behavioral health (n=15). KPI payments to both practices and individual providers corresponded with increased screening rates, whereas capitation and provider-level FFS models yielded mixed results. A large majority of studies assessed changes in screening rates (n=48) with less focus on quality of care (n=11) or workflow changes (n=4). DISCUSSION: Financial mechanisms can enhance screening rates with evidence strongest for KPI payments to both practices and individual providers. Future research should explore the relationship between financial interventions and quality of care, in terms of both clinical processes and patient outcomes, as well as the role of these interventions in shaping care delivery.

Are disparities in mental health care for Medicaid beneficiaries lower in managed care?

BACKGROUND: There are large and persistent racial and ethnic disparities in the use of mental health care in the United States. Medicaid managed care plans have the potential to reduce racial and ethnic disparities in use of mental health care through monitoring of need and active management of use of services across the populations they cover. This study compares racial and ethnic disparities among Medicaid beneficiaries in managed care with those not in managed care. METHODS: We compared Medicaid beneficiaries enrolled health maintenance organizations (HMOs) with those in fee-for-service (FFS) using data from the 2007-2015 Medical Expenditure Panel Survey (N = 26,113). We specified two-part propensity score adjusted models to estimate differences in mental health related emergency department visits, hospital stays, prescription fills, and outpatient visits overall and by race/ethnicity. RESULTS: HMO enrollment was associated with lower odds of having a mental health prescription (OR = 0.86, 95 % CI 0.78-0.96) or outpatient visit (OR = 0.82 95 % CI 0.73-0.92). These differences were similar across racial and ethnic groups or larger among Non-Hispanic Black and Hispanic beneficiaries than among Non-Hispanic White beneficiaries. CONCLUSIONS: Medicaid managed care has not improved the inequitable allocation of mental health care across racial and ethnic groups. Explicit attention to monitoring of racial and ethnic differences in use of mental health care in Medicaid managed care is warranted. IMPLICATIONS: Improvement in racial and ethnic disparities in mental health care in Medicaid manage care is unlikely to occur without targeted accountability mechanisms, such as required reporting or other contracting requirements.

The effect of adverse childhood experience training, screening, and response in primary care: a systematic review.

Background: Adverse childhood experiences (ACEs) can have harmful, long-term health effects. Although primary care providers (PCPs) could help mitigate these effects, no studies have reviewed the impacts of ACE training, screening, and response in primary care. Methods: This systematic review searched four electronic databases (PubMed, Web of Science, APA PsycInfo, CINAHL) for peer-reviewed articles on ACE training, screening, and/or response in primary care published between Jan 1, 1998, and May 31, 2023. Searches were limited to primary research articles in the primary care setting that reported provider-related outcomes (knowledge, confidence, screening behavior, clinical care) and/or patient-related outcomes (satisfaction, referral engagement, health outcomes). Summary data were extracted from published reports. Findings: Of 6532 records, 58 met inclusion criteria. Fifty-two reported provider-related outcomes; 21 reported patient-related outcomes. 50 included pediatric populations, 12 included adults. A majority discussed screening interventions (n = 40). Equal numbers (n = 25) discussed training and clinical response interventions. Strength of evidence (SOE) was generally low, especially for adult studies. This was due to reliance on observational evidence, small samples, and self-report measures for heterogeneous outcomes. Exceptions with moderate SOE included the effect of training interventions on provider confidence/self-efficacy and the effect of screening interventions on screening uptake and patient satisfaction. Interpretation: Primary care represents a potentially strategic setting for addressing ACEs, but evidence on patient- and provider-related outcomes remains scarce. Funding: The California Department of Health Care Services and the Office of the California Surgeon General.

Psychiatric and Substance Use Disorder Bed Capacity, Need, and Shortage Estimates in California: Merced, San Joaquin, and Stanislaus Counties.

Psychiatric and substance use disorder (SUD) treatment beds are essential infrastructure for meeting the needs of individuals with behavioral health conditions. However, not all psychiatric and SUD beds are alike: They represent infrastructure within different types of facilities. For psychiatric beds, these vary from acute psychiatric hospitals to community residential facilities. For SUD treatment beds, these vary from facilities offering short-term withdrawal management services to others offering longer duration residential detoxification services. Different settings also serve clients with different needs. For example, some clients have high-acuity, short-term needs; others have longer-term needs and may return for care on multiple occasions. California's Merced, San Joaquin, and Stanislaus Counties, like other counties throughout the United States, have sought to assess shortages in psychiatric and SUD treatment beds. In this study, the authors estimated psychiatric bed and residential SUD treatment capacity, need, and shortages for adults and children and adolescents at various levels of care: acute, subacute, and community residential services for psychiatric treatment and SUD treatment service categories defined by American Society of Addiction Medicine clinical guidelines. Drawing from various data sets, literature review findings, and facility survey responses, the authors computed the number of beds required-at each level of care-for adults and children and adolescents and identified hard-to-place populations. The authors draw from these findings to offer Merced, San Joaquin, and Stanislaus Counties recommendations to help ensure all their residents, especially nonambulatory individuals, have access to the behavioral health care that they need.

Association between hospital-physician vertical integration and medication adherence rates.

OBJECTIVE: To test the association between vertical integration of primary care providers (PCPs) and adherence rates for anti-diabetics, renin angiotensin system antagonists (RASA), and statins. DATA SOURCES: Medicare Part B outpatient fee-for-service claims and Medicare Part D event data from 2014 to 2017. STUDY DESIGN: We estimated difference-in-differences regressions, comparing changes in adherence among patients with PCPs who converted from independent to integrated to changes among patients whose PCPs remained independent or integrated during the study period. To test for heterogenous impacts by patient demographics, we estimated triple difference regressions that included additional interaction terms by comorbidity rates, age group, and race/ethnicity. EXTRACTION METHODS: We extracted Medicare claims for adults with continuous enrollment in Parts B and D during the study period. PRINCIPAL FINDINGS: The proportion of patients who had a vertically integrated PCP increased by approximately 23% over the study period. Changes in adherence did not differ significantly between patients based on whether their PCP became integrated (Statins: 0.18, 95% CI -0.13, 0.49; RASA: -0.13, 95% CI -0.46, 0.19; Anti-Diabetics: -0.20, 95% CI -0.78, 0.38). Among patients with PCPs who became integrated, there were significant decreases in adherence for patients who were Black, Asian, Hispanic, or Native American, above 80 years old, and had greater comorbidities for all three classes. CONCLUSIONS: While there were no average changes in adherence following vertical integration of PCPs, health equity worsened, with significant declines in adherence for Black, Asian, Hispanic, and Native American patients, patients over 80 years old, and patients with greater comorbidities. These findings suggest that integration may reduce clinicians' incentives to compete based on the quality of care delivered. Given the price increases associated with integration, integration may be a net welfare loss.

New prescription fills of selective serotonin reuptake inhibitors before and during the COVID-19 pandemic in Los Angeles County, California.

OBJECTIVE: This study examined whether the COVID-19 pandemic was associated with changes in new selective serotonin reuptake inhibitor (SSRI) prescription fills. METHODS: Using IQVIA Xponent data on new SSRI fills in Los Angeles (L.A.) County from March 2019 to June 2021, the authors implemented an interrupted time series analysis comparing the monthly volume and trend of overall fills and fills by age and gender from before to after the pandemic declaration. RESULTS: The rate of new SSRI prescription fills briefly decreased after the pandemic declaration but then consistently increased through the rest of the study period. These increases were primarily driven by women, young adults (i.e., 18-39 year-olds), and those under 18 years old. LIMITATIONS: Sample is limited to one county and may not be generalizable to other municipalities. CONCLUSIONS: The COVID-19 pandemic was associated with significant increases in new SSRI fills among women, young adults, and those under 18. These increases were relatively small compared to increases in depressive symptoms during the same time period.

Differences in buprenorphine treatment quality across physician provider specialties.

BACKGROUND: The number and types of clinicians prescribing buprenorphine treatment for opioid use disorder (OUD) have increased over the past two decades, but there is little information on how potential indicators of quality of care to patients receiving buprenorphine vary by provider specialty. METHODS: We used the Medicaid Analytic eXtract from 2009 to 2014 to identify buprenorphine treatment episodes. We assigned physician specialties to episodes based on whether an episode had at least one outpatient claim linked to specialists in addiction, behavioral health, opioid treatment program (OTP), pain, or primary care provider (PCP). We then used logistic regressions to estimate the association of linked physician specialty and achievement of the following process of care measures: at least 180-day duration, no co-occurring opioid analgesics, no co-occurring benzodiazepines, infectious disease screening, liver function test, drug and toxicology screenings, evaluation and management visits, and counseling. RESULTS: Episodes linked to PCPs had significantly lower odds of achieving 180-day duration, an absence of opioid analgesics, an absence of benzodiazepines, drug and toxicology screenings, and counseling compared to addiction, behavioral health, and/or OTPs. Episodes linked to PCPs had significantly higher odds of undergoing infectious disease screenings, liver function tests, and evaluation and management visits compared to all specialty categories. CONCLUSIONS: Episodes were more likely to achieve process of care measures related to the specialties of their physicians, but no specialty consistently demonstrated better performance compared to PCPs. Our findings highlight the need for models that can better integrate physical and behavioral health services for OUD treatment.

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.

Cost-effectiveness of total state coverage for hepatitis C medications.

OBJECTIVES: Most Medicaid beneficiaries with hepatitis C virus (HCV) are not treated with direct-acting agents because of budget constraints, but they experience costly complications after becoming Medicare eligible. Maryland's "total coverage" proposal could receive a credit from Medicare to offset Medicaid investments in treatments that could lead to Medicare savings. This study analyzes the cost-effectiveness and budget impact of total coverage for HCV treatments sponsored by state Medicare and Medicaid. STUDY DESIGN: A Markov model simulated patients going through the care continuum of HCV. The model simulated 3 pathways: standard coverage with a 50% probability of screening for HCV and 20% probability of treatment; risk-stratified total coverage with assumed 80% probability of screening and 60% treatment rate; and total coverage with assumed 80% probability of screening and 100% treatment rate. METHODS: The model calculated US$ and quality-adjusted life-years (QALYs) to produce an incremental cost-effectiveness ratio evaluated at a willingness-to-pay threshold of $100,000/QALY. The budget impact for the state of Maryland was calculated in terms of per member per year. RESULTS: Total coverage and risk-stratified coverage saved $158 per patient and $178 per patient, respectively, compared with standard care at an increased effectiveness of 0.05 and 0.02 QALYs over 25 years. Total coverage and risk-stratified total coverage would save $1.0 billion and $1.1 billion, respectively, after 25 years. CONCLUSIONS: Medicare-Medicaid partnerships to pay for all HCV treatments today represent good value and a low budget impact. States with trouble covering HCV treatments should consider using this model to plan coverage decisions.

Does Incorporating Cost-Effectiveness Analysis Into Prescribing Decisions Promote Drug Access Equity?

Using cost-effectiveness analysis (CEA) to inform prescribing can promote equitable drug access from a utilitarian perspective. Some theorists of equity, such as Rawls or Powers and Faden, however, would not consider CEA as promoting equity, as they endorse nonutilitarian theories of equity. Novel advances in CEA methodology seek to integrate broader equity concerns but may raise transparency concerns. We argue that incorporating CEA into qualitative multi-criteria decision analysis to inform prescribing decisions could promote equity more effectively and transparently than using CEA alone. Such applications should be implemented, along with recommendations, at the health system level rather than be carried out by individual clinicians alone.

Use and cost of disease-modifying therapies by Sonya Slifka Study participants: has anything really changed since 2000 and 2009?

BACKGROUND: Disease-modifying therapies benefit individuals with relapsing forms of multiple sclerosis, but their utility remains unclear for those without relapses. OBJECTIVE: To determine disease-modifying therapy use and costs in 2009, compare use in 2009 and 2000, and examine compliance with evidence-based guidelines. METHODS: We determined the extent and characteristics of disease-modifying therapy use by participants in the Sonya Slifka Longitudinal Multiple Sclerosis Study (Slifka) in 2000 (n=2156) and 2009 (n=2361) and estimated out-of-pocket and total (payer) costs for 2009. Two multivariable logistic regressions predicted disease-modifying therapy use. RESULTS: Disease-modifying therapy use increased from 55.3% in 2000 to 61.5% in 2009. In 2009, disease-modifying therapy use was reported by 76.5% of participants with relapsing-remitting multiple sclerosis, 73.2% with progressive-relapsing multiple sclerosis, 62.5% with secondary progressive multiple sclerosis, and 41.8% with primary progressive multiple sclerosis. Use was significantly associated with relapsing-remitting multiple sclerosis, shorter duration of illness, one to two relapses per year, non-ambulatory symptoms, using a cane, younger age, higher family income, and having health insurance. Average annual costs in 2009 were US$939-3101 for patients and US$16,302-18,928 for payers. CONCLUSION: Use rates were highest for individuals with relapsing-remitting multiple sclerosis, but substantial for those with progressive courses although clinical trials have not demonstrated significant benefits for them.