Prevalence of Buprenorphine Providers Requiring Cash Payment From Insured Women Seeking Opioid Use Disorder Treatment.

CONTEXT: Medications for opioid use disorder (OUD) are known to be effective, especially in reducing the risk of overdose death. Yet, many individuals suffering from OUD are not receiving treatment. One potential barrier can be the patient's ability to access providers through their insurance plans. DATA AND METHODS: We used an audit (simulated patient) study methodology to examine appointment-granting behavior by buprenorphine prescribers in 10 different US states. Trained callers posed as women with OUD and were randomly assigned Medicaid or private insurance status. Callers request an OUD treatment appointment and then asked whether they would be able to use their insurance to cover the cost of care, or alternatively, whether they would be required to pay fully out-of-pocket. FINDINGS: We found that Medicaid and privately insured women were often asked to pay cash for OUD treatment--40% of the time over the full study sample. Such buprenorphine provider requests happened more than 60% of the time in some states. Areas with more providers or with more generous provider payments were not obviously more willing to accept the patient's insurance benefits for OUD treatment. Rural providers were less likely to require payment in cash in order for the woman to receive care. CONCLUSIONS: State-to-state variation was the most striking pattern in our field experiment data. The wide variation suggests that women of reproductive age with OUD in certain states face even greater challenges to treatment access than perhaps previously thought; however, it also reveals that some states have found ways to curtail this problem. Our findings encourage greater attention to this public health challenge and possibly opportunities for shared learning across states.

Physician patient sharing relationships within insurance plan networks.

OBJECTIVE: To quantify shared patient relationships between primary care physicians (PCPs) and cardiologists and oncologists and the degree to which those relationships were captured within insurance networks. DATA SOURCES: Secondary analysis of Vericred data on physician networks, CareSet data on physicians' shared Medicare patients, and insurance plan attributes from Health Insurance Compare. Data validation exercises used data from Physician Compare and IQVIA. STUDY DESIGN: Cross-sectional study of the PCP-to-specialist in-network shared patient percentage (primary outcome). We also categorized networks by insurance market segment (Medicare Advantage [MA], Medicaid managed care, small-group or individually purchased), insurance plan type, and network breadth. DATA EXTRACTION: We analyzed data on 219,982 PCPs, 29,400 cardiologists, and 22,745 oncologists who, in 2021, accepted MA (n = 941 networks), Medicaid managed care (n = 293), and individually-purchased (n = 332) and small-group (n = 501) plans. PRINCIPAL FINDINGS: Networks captured, on average, 64.6% of PCP-cardiology shared patient ties, and 61.8% of PCP-oncologist ties. Less than half of in-network ties (44.5% and 38.9%, respectively) were among physicians with a common organizational affiliation. After adjustment for network breadth, we found no evidence of differences in the shared patient percentage across insurance market segments or networks of different types (p-value >0.05 for all comparisons). An exception was among national versus local and regional networks, where we found that national plans captured fewer shared patient ties, particularly among the narrowest networks (58.4% for national networksvs. 64.7% for local and regional networks for PCP-cardiology). CONCLUSIONS: Given recent trends toward narrower networks, our findings underscore the importance of incorporating additional and nuanced measures of network composition to aid plan selection (for patients) and to guide regulatory oversight.

Traditional Medicare Episode-Related Spending on Postacute Care for Dual-Eligible and Medicare-Only Beneficiaries, 2009-2017.

Dual-eligible beneficiaries with Medicare and Medicaid coverage generally have greater utilization and spending levels than Medicare-only beneficiaries on postacute services, raising questions about how strategies to curb postacute spending will affect dual-eligible beneficiaries. We compared trends in postacute spending and use related to inpatient episodes at a population and episode level for dual-eligible and Medicare-only beneficiaries over the years 2009-2017. Although dual-eligible beneficiaries had consistently higher inpatient and postacute service use and spending than Medicare-only populations, both populations experienced similar declines in inpatient and postacute measures over time. Conditional on having an inpatient stay, most types of postacute service use increased regardless of dual-eligible status. These consistent patterns in episode-related postacute spending for Medicare-only and dual-eligible beneficiaries-decreased episode-related spending and use on a per beneficiary basis and increased use and spending on a per episode basis-suggest that changing patterns of care affect both populations.

Association of Race and Income with Incident Diagnosis of Alzheimer's Disease and Related Dementias among Black and White Older Adults.

To investigate how differences in income and education levels may contribute to disparities in incidence of Alzheimer's disease and related dementia (ADRD), we compared ADRD incidence in traditional Medicare claims for 11,132 Black and 7703 White participants aged 65 and over from a predominantly low-income cohort. We examined whether the relationship between ADRD incidence and race varied by income or education. Based on 2015 incident ADRD diagnoses, Black and White participants had unadjusted incidence rates of 26.5 and 23.2 cases per 1000 person-years, respectively (rate ratio 1.14, 95% CI 1.05-1.25). In multivariable Cox proportional hazard models, the relationship between race and incident ADRD diagnosis did not vary by education level (p-interaction = 0.748) but was modified by income level (p-interaction = 0.007), with higher ADRD incidence among Black participants observed only among higher income groups. These results highlight the importance of understanding how race and economic factors influence ADRD incidence and diagnosis rates.

Trends in and Factors Contributing to the Slowdown in Medicare Spending Growth, 2007-2018.

Importance: After decades of rapid increase, Medicare per-beneficiary spending growth was historically low in the period leading up to the passage of the Affordable Care Act. In the years immediately following the legislation, Medicare expenditure growth slowed even further. Objective: To evaluate factors contributing to the slowdown in Medicare per-beneficiary spending growth. Design, Setting, and Participants: In this cross-sectional study, expected spending growth for 2012 to 2015 and 2016 to 2018 was predicted holding payment rates and population characteristics constant. By contrasting predicted and actual spending growth during these periods, the contribution of population vs payment factors to the Medicare spending slowdown was determined. Analyses included all Medicare fee-for-service beneficiaries aged 65 years and older, ranging from 30 to 35 million beneficiaries annually between 2007 and 2018. Data analyses were conducted from January 2018 to August 2018 and updated with new data in June 2021. Main Outcomes and Measures: The main outcome included annual growth in total per-beneficiary spending. The roles of payment rate changes and differences in the Medicare population over time were considered, including demographic characteristics and numbers of chronic conditions. Results: Between 2008 to 2011 and 2012 to 2015, the adjusted annual Medicare Parts A and B per-beneficiary spending growth rate declined from 3.3% to -0.1%. From 2016 to 2018, the mean annual Medicare spending growth rate rose relative to the previous period but remained lower than in the baseline period at 1.7% per year. This slowdown extended across all sectors within Parts A and B, except for physician-administered drugs offered under Part B. Changes in payment rates (including sequestration measures) and beneficiary characteristics explained 44% of the difference in overall per-beneficiary spending growth between 2007 to 2011 and 2012 to 2015, and 63% between 2007 to 2011 and 2016 to 2018. Conclusions and Relevance: In this cross-sectional study of trends in spending growth per Medicare beneficiary aged 65 years or older, results suggested that Medicare payment policy, including sector-specific payment rate changes and sequestration, will be a critical determinant of whether the Medicare spending growth slowdown persists.

An algorithm using administrative data to measure adverse childhood experiences (ADM-ACE).

OBJECTIVE: To develop an algorithm using administrative data to measure adverse childhood experiences (ADM-ACE) within routinely collected health insurance claims and enrollment data. DATA SOURCES: We used claims and enrollment data from Tennessee's Medicaid program (TennCare) in 2018. STUDY DESIGN: We studied five types of ACEs: maltreatment and peer violence, foster care and family disruption, maternal mental illness, maternal substance use disorder, and abuse of the mother. We used diagnosis and procedure codes, prescription drug fills, and enrollment files to develop the ADM-ACE, which we applied to measure the prevalence of ACEs and to examine prevalence by demographic characteristics among our sample of children in TennCare. We compared ADM-ACE prevalence to child welfare records and survey results from Tennessee. DATA COLLECTION/EXTRACTION METHODS: Our study sample included children aged 0-17 years who were linked to their mothers if also enrolled in TennCare in 2018 (N = 763,836 children). PRINCIPAL FINDINGS: Approximately 19.2% of children in TennCare had indicators for ADM-ACEs. The prevalence of ACEs was higher among children who were younger (p < 0.001), non-Hispanic white or black (compared to Hispanic) (p < 0.001), and children residing in rural versus urban counties (p < 0.001). The prevalence of maltreatment identified through the ADM-ACE (1.6%) falls between the percent of children in Tennessee who were reported to child welfare authorities and the percent for whom reports of maltreatment were substantiated. Comparison with survey reports from Tennessee parents suggests an advantage in measuring maternal mental illness with the ADM-ACE using health insurance claims data. CONCLUSIONS: The ADM-ACE can be applied to health encounter data to study and monitor the prevalence of certain ACEs, their association with health conditions, and the effects of policies on reducing exposure to ACEs or improving health outcomes for children with ACEs.

Medicaid prevalence and opioid use disorder treatment access disparities.

OBJECTIVE: To examine how variation in the size of the local Medicaid population moderates Medicaid-to-private treatment access differentials for women with opioid use disorder (OUD). DATA SOURCES: County-level information on total Medicaid enrollment combined with randomized field experiment data from 10 diverse states that used a simulated patient (audit) methodology to examine buprenorphine providers' appointment granting behavior. STUDY DESIGN: We used multiple regression modeling approaches to capture the moderating influence of Medicaid prevalence on differences in the likelihood of receiving an insurance-covered appointment between Medicaid and privately insured female patients. DATA EXTRACTION: Completed calls to buprenorphine treatment providers. PRINCIPAL FINDINGS: We find a 0.37 percentage point (p value <0.01) narrowing of the Medicaid-to-private access gap with each one percentage point increase in the local insured population on Medicaid. There is effectively no difference in the likelihood of being granted an insurance-covered appointment across the two payer groups in the top tercile of Medicaid penetration. CONCLUSIONS: When Medicaid is a common source of insurance within the local population, buprenorphine providers are much less likely to discriminate between Medicaid and privately insured prospective patients. Efforts to enhance equitable access across patient groups are perhaps best targeted where Medicaid prevalence is lower.

Disparities in receipt of medications for opioid use disorder among pregnant women.

Background: Medications for opioid use disorder (MOUD) improve outcomes for pregnant women and infants. Our primary aim was to examine disparities in maternal MOUD receipt by family sociodemographic characteristics. Methods: This retrospective cohort study included mother-infant dyads with Medicaid-covered deliveries in Tennessee from 2009 to 2016. First, we examined family sociodemographic characteristics - including race/ethnicity, rurality, mother's primary language and education level, and whether paternity was recorded in birth records - and newborn outcomes by type of maternal opioid use. Second, among pregnant women with OUD, we used logistic regression to measure disparities in receipt of MOUD by family sociodemographic characteristics including interactions between characteristics. Results: Our cohort from Medicaid-covered deliveries consisted of 314,965 mother-infant dyads, and 4.2 percent were exposed to opioids through maternal use. Among dyads with maternal OUD, MOUD receipt was associated with lower rates of preterm and very preterm birth. Logistic regression adjusted for family sociodemographic characteristics showed that pregnant women with OUD in rural versus urban areas (aOR: 0.66; 95% CI: 0.60-0.72) and who were aged ≥35 years versus ≤25 years (aOR: 0.75; 95% CI: 0.64-0.89) were less likely to have received MOUD. Families in which the mother's primary language was English (aOR: 2.47; 95% CI: 1.24-4.91) and paternity was recorded on the birth certificate (aOR: 1.30; 95% CI: 1.19-1.42) were more likely to have received MOUD. Regardless of high school degree attainment, non-Hispanic Black versus non-Hispanic White race was associated with lower likelihood of MOUD receipt. Hispanic race was associated with lower likelihood of MOUD receipt among women without a high school degree. Conclusions: Among a large cohort of pregnant women, we found disparities in receipt of MOUD among non-Hispanic Black, Hispanic, and rural pregnant women. As policymakers consider strategies to improve access to MOUD, they should consider targeted approaches to address these disparities.

Traditional Medicare Spending on Inpatient Episodes as Hospitalizations Decline.

OBJECTIVE: To describe Medicare inpatient episode spending trends between 2009 and 2017 as inpatient use declined among traditional Medicare beneficiaries. METHODS: Inpatient episodes included claims for all traditional Medicare inpatient, outpatient, and Part D services provided during the 30 days prehospitalization, the inpatient stay, and the 90 subsequent days. We describe the mean number of episodes per 1000 beneficiaries, mean episode-related spending per beneficiary, and mean spending per episode for all beneficiaries and for specific populations and types of episodes. Spending measures are reported with and without adjustment for payment rate increases over the study period. RESULTS: The number of inpatient-initiated episodes per 1000 beneficiaries declined by 18.2% between 2009 and 2017 from 326 to 267. After adjusting for payment rate increases, Medicare spending per beneficiary on episode- related care declined by 8.9%, although spending per episode increased by 11.4% over this period. Between 2009 and 2017, all subgroups defined by age, sex, race, or Medicaid status experienced declines in inpatient use accompanied by decreased overall episode-related spending per beneficiary and increased spending per episode. Larger declines in the number of episodes per 1000 beneficiaries were seen among episodes that began with a planned admission (28.8%) or involved no use of post-acute care services (23.9%). When comparing admissions according to medical diagnosis, the largest decline occurred for episodes initiated by a hospitalization for a cardiac or circulatory condition (31.8%). CONCLUSION: Medicare inpatient episodes per beneficiary decreased, but spending decreases due to declining volume were offset by increased spending per episode.

Association of Pregnancy and Insurance Status With Treatment Access for Opioid Use Disorder.

Importance: Medications for opioid use disorder, including buprenorphine hydrochloride and methadone hydrochloride, are highly effective at improving outcomes for individuals with the disorder. For pregnant women, use of these medications also improves pregnancy outcomes, including the risk of preterm birth. Despite the known benefits of medications for opioid use disorder, many pregnant and nonpregnant women with the disorder are not receiving them. Objective: To determine whether pregnancy and insurance status are associated with a woman's ability to obtain an appointment with an opioid use disorder treatment clinician. Design, Setting, and Participants: In this cross-sectional study with random assignment of clinicians and simulated-patient callers (performed in "secret shopper" format), outpatient clinics that provide buprenorphine and methadone were randomly selected from publicly available treatment lists in 10 US states (selected for variability in opioid-related outcomes and policies) from March 7 to September 5, 2019. Pregnant vs nonpregnant woman and private vs public insurance assigned randomly to callers to create unique patient profiles. Simulated patients called the clinics posing as pregnant or nonpregnant women to obtain an initial appointment with a clinician. Main Outcomes and Measures: Appointment scheduling, wait time, and out-of-pocket costs. Results: A total of 10 871 unique patient profiles were assigned to 6324 clinicians. Among all women, 2312 of 3420 (67.6%) received an appointment with a clinician who prescribed buprenorphine, with lower rates among pregnant vs nonpregnant callers (1055 of 1718 [61.4%] vs 1257 of 1702 [73.9%]; relative risk, 0.83; 95% CI, 0.79-0.87). For clinicians who prescribed methadone, there was no difference in appointment access for pregnant vs nonpregnant callers (240 of 271 [88.6%] vs 237 of 265 [89.4%]; relative risk, 0.99; 95% CI, 0.93-1.05). Insurance was frequently not accepted, with 894 of 3420 buprenorphine-waivered prescribers (26.1%) and 174 of 536 opioid treatment programs (32.5%) granting appointments only when patients agreed to pay cash. Median wait times did not differ between pregnant and nonpregnant callers among buprenorphine prescribers (3 days [interquartile range, 1-7 days] vs 3 days [interquartile range, 1-7 days]; P = .43) but did differ among methadone prescribers (1 day [interquartile range, 1-4 days] vs 2 days [interquartile range, 1-6 days]; P = .049). For patients agreeing to pay cash, the median out-of-pocket costs for initial appointments were $250 (interquartile range, $155-$300) at buprenorphine prescribers and $34 (interquartile range, $15-$120) at methadone prescribers. Conclusions and Relevance: In this cross-sectional study with random assignment of clinicians and simulated-patient callers, many women, especially pregnant women, faced barriers to accessing treatment. Given the high out-of-pocket costs and lack of acceptance of insurance among many clinicians, access to affordable opioid use disorder treatment is a significant concern.

Risk adjusting for Medicaid participation in Medicare Advantage.

OBJECTIVES: Determining appropriate capitated payments has important access implications for dual-eligible Medicare Advantage (MA) members. In 2017, MA plans began receiving higher capitated payments for beneficiaries with full vs partial Medicaid when payments started being risk adjusted for level of Medicaid benefits instead of any Medicaid participation. This approach could favor MA plans in states with more generous Medicaid programs where more beneficiaries qualify for full Medicaid and thus a higher capitated payment. To understand this issue, we examined adjusted Medicare spending for dual-eligible beneficiaries across states with differing Medicaid eligibility criteria. STUDY DESIGN: Retrospective analysis of 2007-2015 traditional Medicare data for dual-eligible beneficiaries 65 years and older. METHODS: We compared predicted per-beneficiary spending levels after adjusting for any Medicaid participation and for level of Medicaid benefits across states with varying Medicaid eligibility requirements. RESULTS: States with the most generous Medicaid requirements had more dual-eligible beneficiaries with full Medicaid compared with the most restrictive states (median, 82% vs 55%). Nationally, Medicare spending levels were 1.3 times greater for full vs partial Medicaid participants (range across states, 0.8-1.7). When per-beneficiary spending was adjusted for level of Medicaid benefits, rather than any Medicaid participation, states with more generous Medicaid eligibility had larger gains in predicted spending per dual-eligible beneficiary than states with less generous Medicaid coverage (1.7% vs 1.3% increase). CONCLUSIONS: Distinguishing between partial and full Medicaid in MA payments may disproportionately increase MA payments in states that have more full Medicaid beneficiaries due to more generous Medicaid eligibility.

Relationship between initiation of 340B participation and hospital safety-net engagement.

OBJECTIVE: The 340B program allows safety-net hospitals to acquire discounted outpatient drugs and charge payers full price. We examined whether 340B participation increases safety-net engagement. DATA SOURCES: 340B participation data, Medicare hospital cost reports, American Hospital Association Survey, and Schedule 990 nonprofit hospital tax returns. STUDY DESIGN: Quasi-experimental difference-in-differences design comparing 340B hospitals (the "treatment" group) before and after participating to changes over time to three alternative "control" groups: all other nonprofit and public hospitals, hospitals that are not participating during our study, and hospitals that were not-yet-participating but started after 2015. Outcome measures include a range of safety-net care measures that are alternatives to the standard uncompensated care: charity care, community benefit spending, charity care policies, and low-profit service-line provision. DATA EXTRACTION: We extracted data on all nonprofit and public hospitals from 2011 to 2015. We linked 340B participation data to Medicare hospital cost reports and American Hospital Association data using Medicare hospital identifiers. 990 Data was linked on name and address. PRINCIPAL FINDINGS: New 340B participation was not associated with a change in uncompensated care, but was associated with a 28.9 percent increase in charity care spending (SE = 8.8), or about $880,000 per hospital. However, total community benefit spending (including charity care) did not change. 340B was associated with an increase in the probability of offering discounted care (4.3 percentage points, SE = 1.6) from 84 to 88 percent and an increase in the income eligibility limit for discounted care (18.9 percentage points, SE = 5.6) from 294 to 313 percent. Participation was not associated with the probability of offering low-profit medical care services. CONCLUSIONS: Alternative measures show that newly participating hospitals may increase charity care, potentially through offering more patients discounted care. However, increases appear to be fully offset by reductions in other community benefit programs.