Patient experiences with outpatient opioid use disorder treatment before and during COVID-19: results from a survey of Medicaid members.

Background: Payers are increasingly interested in quality improvement for opioid use disorder (OUD) treatment, including incorporating patient experiences. Medicaid is the largest payer for OUD treatment, yet we know little about the treatment benefits Medicaid members report, how these vary across members, or changed with the COVID-19 pandemic.Objective: To examine Medicaid members' report of outpatient treatment benefits, employment, and housing outcomes before and during the pandemic.Methods: A representative sample of 1,032 Virginia Medicaid members (52% women) receiving OUD treatment completed a survey of treatment benefits, health status and social needs. A reported treatment benefit index was created based on seven self-reported items. Multivariable linear regression models, pooled and stratified by time (pre-COVID-19/COVID-19), assessed member characteristics associated with reported treatment benefit, employment and housing outcomes.Results: Members reported strong treatment benefit (mean: 21.8 [SD: 5.9] out of 28 points) and improvements in employment (2.4 [1.3] out of 5) and housing (2.8 [1.2] out of 5). After adjustment, mental distress (regression coefficient: -3.00 [95% CI:-3.97;-2.03]), polysubstance use (-1.25 [-1.99;-0.51]), and food insecurity (-1.00 [-1.71;-0.29]), were associated with decreased benefits from treatment. During COVID-19, justice-involved individuals reported decreased benefits (-2.17 [-3.54; -0.80]) compared to before the pandemic (-0.09 [-1.4-;1.24] p < .05).Conclusions: Medicaid members receiving outpatient OUD treatment reported positive treatment benefits, and housing and employment outcomes. However, those with comorbid health and social conditions often benefited the least. As payers move toward quality improvement and value-based purchasing initiatives, collecting and integrating patient reported outcomes into quality metrics is critical.

Associations Between Patient-Reported Experiences with Opioid Use Disorder Treatment and Unmet Treatment Needs and Discontinuation Among Virginia Medicaid Members.

BACKGROUND: Many payers, including Medicaid, the largest payer of opioid use disorder (OUD) treatment, are pursuing treatment-related quality improvement initiatives. Yet, how patient-reported experiences with OUD treatment relate to patient-centered outcomes remains poorly understood. AIM: To examine associations between Medicaid members' OUD treatment experiences, outpatient treatment settings, demographic and social factors, and members' self-report of unmet needs during treatment and treatment discontinuation. METHODS: A sample of Virginia Medicaid members aged 21 years or older with OUD diagnoses who received outpatient OUD treatment completed a mail survey between January 2020 and August 2021 (n = 1042, weighted n = 9244). A treatment experience index was constructed from responses to four items from the Consumer Assessment of Healthcare Providers and Systems (CAHPS) relating to feelings of involvement, safety, and respect and having treatment explained in an understandable way; two additional CAHPS items: "given options for treatment" and "able to refuse treatment" were also assessed. Weighted imputed logistic regressions tested adjusted associations between members' treatment experiences, demographic and social factors, and two outcomes capturing unmet needs during treatment and treatment discontinuation. RESULTS: More positive scores on the treatment experiences index were associated with lower adjusted odds of reporting unmet needs during treatment (aOR: 0.52, 95% CI: 0.41-0.66) and discontinuation (aOR: 0.63, 95% CI: 0.47-0.79). Respondents with serious psychological distress had higher odds of reporting unmet needs during treatment (aOR: 1.69 95% CI: 1.14-2.51) and discontinuation (aOR: 1.84, 95% CI: 1.21-2.82), as did individuals with housing insecurity (unmet needs: (aOR: 1.65, 95% CI: 1.11-2.44); treatment discontinuation: (aOR: 1.56, 95% CI: 1.04-2.36)). CONCLUSION: Using a first-of-its-kind survey of Medicaid members with OUD, we found that members who had more positive treatment experiences were less likely to report unmet treatment needs and discontinue treatment. Care approaches focused on improving patient experience are critical to delivering effective, high-quality OUD treatment.

Resource asymmetry reduces generosity and paying forward generosity, among the resource-advantaged and disadvantaged.

Decisions to benefit others often entail generalized reciprocity: helping someone who cannot directly return benefits in the future; instead, the beneficiary may "pay it forward" to someone else. While much past work demonstrates that people pay forward generosity, experimental tests of these processes typically assume that people have equal access to same-valued resources that they can use to benefit others. Yet this is rare in daily life, where people commonly experience asymmetries in the resources that they have to help others and to pay forward help received. In an experiment, we find that acts of generalized reciprocity-including initiating generosity and, upon being treated generously, paying it forward-are reduced when there is resource asymmetry between potential benefactors. Results show that the detriments of resource asymmetry occur among both the resource-advantaged and the disadvantaged. Asymmetry in available resources, and inequality more broadly, is thus critical for understanding patterns of generosity.

Identifying bright spot communities: Socioecological, workforce, and healthcare delivery factors influencing opioid mortality.

Context: There were 50,000 U.S. opioid overdose deaths in 2019. Millions suffer from opioid addiction. Identifying protective factors for low community opioid mortality may have important implications for addressing the opioid epidemic. This study was funded through the Virginia (VA) Department of Medical Assistance Services (DMAS) through a SUPPORT Act Grant. Objective: To identify "Bright Spot" communities in Virginia with protective factors associated with reduced opioid mortality and morbidity. Study Design: Ecologic study. Dataset: Virginia All Payer Claims Database (APCD), Virginia Department of Health (VDH) statewide medical examiner registry, and American Community Survey (ACS). Time Period: 2016-2019; 2019 data cited here. Population Studied: APCD includes VA residents with medical claims through commercial, Medicaid, and Medicare coverage. VDH data includes fatal drug overdoses. ACS surveys all VA residents. Outcome Measures: Primary outcome: fatal opioid overdoses. Secondary outcomes: emergency room visits for overdoses and opioid-related diagnoses, outpatient diagnoses for opioid-related disorder, prescription rate for opioids, and prescription rate for buprenorphine. Results: Opioid mortality was associated with higher rates of community poverty (r=.38, p<.0001) and disability (r=.52, r<.0001). Opioid mortality was associated with inequality, with higher Gini index associated with higher opioid mortality (r=.23, p<.0001). A higher percentage of black residents was associated with increased fatal opioid overdoses (r=.37, p<.0001) and ED visits for overdoses (r=.30, p<.0001). A higher percentage of white residents correlated with increased outpatient visits for opioid use disorder (r=.24, p<.0001) and higher rates of buprenorphine (r=.34, p<.0001) and opioid prescriptions (r=.31, p <.0001). Conclusions: These findings suggest significant racial disparities in opioid outcomes. Communities with a higher percentage of black residents are more likely to have higher opioid mortality and a lower rate of outpatient treatment. This association may be affected by the time period used in the analysis (2015-2019), as nationally there has been an increasing rate of synthetic opioid deaths in Black communities. These measures have been incorporated into a multivariate analysis to identify Bright Spot communities, which will be discussed during the presentation.

Cooperation, clustering, and assortative mixing in dynamic networks.

Humans' propensity to cooperate is driven by our embeddedness in social networks. A key mechanism through which networks promote cooperation is clustering. Within clusters, conditional cooperators are insulated from exploitation by noncooperators, allowing them to reap the benefits of cooperation. Dynamic networks, where ties can be shed and new ties formed, allow for the endogenous emergence of clusters of cooperators. Although past work suggests that either reputation processes or network dynamics can increase clustering and cooperation, existing work on network dynamics conflates reputations and dynamics. Here we report results from a large-scale experiment (total n = 2,675) that embedded participants in clustered or random networks that were static or dynamic, with varying levels of reputational information. Results show that initial network clustering predicts cooperation in static networks, but not in dynamic ones. Further, our experiment shows that while reputations are important for partner choice, cooperation levels are driven purely by dynamics. Supplemental conditions confirmed this lack of a reputation effect. Importantly, we find that when participants make individual choices to cooperate or defect with each partner, as opposed to a single decision that applies to all partners (as is standard in the literature on cooperation in networks), cooperation rates in static networks are as high as cooperation rates in dynamic networks. This finding highlights the importance of structured relations for sustained cooperation, and shows how giving experimental participants more realistic choices has important consequences for whether dynamic networks promote higher levels of cooperation than static networks.

Better together: Third party helping is enhanced when the decision to help is made jointly.

When spouses decide together how much of their joint income to donate to charity, or the parents of several children in a classroom agree to chip in for the cost of a group gift for a teacher, they are engaging in a joint act of benefiting a third party. Past work has typically conceptualized the decision to provide benefits to others as an individual one. But as these examples illustrate, the decision to engage in third-party helping is often initiated at the group level. And there are compelling reasons to expect that the helping behavior initiated jointly by multiple people will differ from that initiated by individuals, even after holding constant the costs and benefits of helping. Here I demonstrate that people provide more benefits to a third party when they must come to an agreement with another benefactor about a joint helping decision, compared to when they communicate about the decision, but then make decisions separately, or when they make helping decisions alone. I show that this is because people engage in generous "talk" in communication with other benefactors - and joint decisions, but not individual decisions, bind them to the high levels of helping that they discuss. Put differently, results show that when people make decisions individually, they give according to their individual preferences about benefiting others; when they make decisions jointly, they give according to their public statements about benefiting others, which tend to be more other-regarding. The results have important implications for understanding the mechanisms driving prosocial behavior.

The status value theory of power and mechanisms of micro stratification: Theory and new experimental evidence.

This paper employs sociological theories of status and power to explore the mechanisms wherein status characteristics produce power in exchange relations. Theories in the status and exchange literature suggest that status characteristics produce power most strongly when actors possess (i) multiple differentiating status characteristics, and (ii) multiple resources. An experiment manipulating these factors finds that the former is related to expectations of competence while the latter induces perceptions of status value - mechanisms whereby status produces power. A second experiment manipulates the race and gender of the participants enabling white males to negotiate with African-American females in dyads. This study produces some of the largest dyadic power differences ever reported in micro sociology. These findings have implications for the mechanisms of power from Thye's (2000a) status value theory of power and Berger and Fisek's (2006) formal theory of status value. More generally, this research bears on the rudimentary foundations of social stratification in groups both small and large.

Changes in buprenorphine waivered provider supply after Virginia Medicaid implements the addiction and recovery treatment services program and Medicaid expansion.

BACKGROUND: Shortages of providers authorized to prescribe buprenorphine may limit access to buprenorphine, which studies have shown to be effective in the treatment of opioid use disorder (OUD). OBJECTIVE: To examine whether two state Medicaid policies in Virginia-the Addiction and Recovery Treatment Services (ARTS) program in 2017, and Medicaid expansion in 2019-increased the number of buprenorphine waivered providers (BWP) in Virginia, compared to other southern states in the United States that did not expand Medicaid. METHODS: The study population includes providers authorized to prescribe buprenorphine. We compute the number of BWP per 100,000 people for the study states, overall and for different waiver limits (30, 100 or 275). Using difference-in-difference regression models, we examine changes in BWP rates for Virginia relative to nonexpansion states in the US South between 2015 and 2020. RESULTS: The rate of increase in BWP was higher in Virginia after implementation of ARTS and Medicaid expansion (148 %), compared to southern nonexpansion states over the same time period (115 %). Relative to nonexpansion states in the South, BWP with patient limits of 100 or 275 increased by 7 % in Virginia after ARTS implementation in 2017, and by an additional 22 % after Medicaid expansion in 2019 (p < 0.05 each). CONCLUSIONS: The findings suggest that public policies that expand access to OUD treatment services-including buprenorphine treatment-may also increase the supply of providers authorized to prescribe buprenorphine, helping to alleviate shortages of BWP providers and further increasing access to care.

Disparities in opioid use disorder-related hospital use among postpartum Virginia Medicaid members.

INTRODUCTION: The overdose crisis is increasingly revealing disparities in opioid use disorder (OUD) outcomes by race and ethnicity. Virginia, like other states, has witnessed drastic increases in overdose deaths. However, research has not described how the overdose crisis has impacted pregnant and postpartum Virginians. We report the prevalence of OUD-related hospital use during the first year postpartum among Virginia Medicaid members in the years preceding the COVID-19 pandemic. We secondarily assess how prenatal OUD treatment is associated with postpartum OUD-related hospital use. METHODS: This population-level retrospective cohort study used Virginia Medicaid claims data for live infant deliveries between July 2016 and June 2019. The primary outcome of OUD-related hospital use included overdose events, emergency department visits, and acute inpatient stays. Independent variables of interest were prenatal receipt of medication for OUD (MOUD) and receipt of non-MOUD treatment components in line with a comprehensive care approach (e.g., case management, behavioral health). Both descriptive and multivariate analyses were performed for all deliveries and stratified by White and Black non-Hispanic individuals to bring attention to the devastating impacts of the overdose crisis within communities of color. RESULTS: The study sample included 96,649 deliveries. Over a third were by Black birthing individuals (n = 34,283). Prenatally, 2.5 % had evidence of OUD, which occurred more often among White (4 %) than Black (0.8 %) non-Hispanic birthing individuals. Postpartum OUD-related hospital use occurred in 10.7 % of deliveries with OUD, more commonly after deliveries by Black, non-Hispanic birthing individuals with OUD (16.5 %) than their White, non-Hispanic counterparts (9.7 %), and this disparity persisted in the multivariable analysis (Black AOR 1.64, 95 % CI 1.14-2.36). Postpartum OUD-related hospital events were less frequent for individuals receiving versus not receiving postpartum MOUD within 30 days prior to the event. Prenatal OUD treatment, including MOUD, was not associated with decreased odds of postpartum OUD-related hospital use in the race-stratified models. CONCLUSION: Postpartum individuals with OUD are at high risk for mortality and morbidity, especially Black individuals not receiving MOUD after delivery. An urgent need remains to effectively address the systemic and structural drivers of racial disparities in transitions of OUD care through the one-year postpartum period.

Rising Racial Disparities in Opioid Mortality and Undertreatment of Opioid Use Disorder and Mental Health Comorbidities in Virginia.

Introduction: There were more than 100,000 fatal drug overdoses in the U.S. in 2021 alone. In recent years, there has been a shift in opioid mortality from predominantly White rural communities to Black urban communities. This study aimed to identify the Virginia communities disproportionately affected by the overdose crisis and to better understand the systemic factors contributing to disparities in opioid mortality. Methods: Using the state all-payer claims database, state mortality records, and census data, we created a multivariate model to examine the community-level factors contributing to racial disparities in opioid mortality. We used generalized linear mixed models to examine the associations between socioecologic factors and fatal opioid overdoses, opioid use disorder diagnoses, opioid-related emergency department visits, and mental health diagnoses. Results: Between 2015 and 2020, racial disparities in mortality widened. In 2020, Black males were 1.5 times more likely to die of an opioid overdose than White males (47.3 vs 31.6 per 100,000; p<0.001). The rate of mental health disorders strongly correlated with mortality (ß=0.53, p<0.001). Black individuals are not more likely to be diagnosed with opioid use disorder (ß=0.01, p=0.002) or with mental health disorders (ß= -0.12, p<0.001), despite higher fatal opioid overdoses. Conclusions: There are widening racial disparities in opioid mortality. Untreated mental health disorders are a major risk factor for opioid mortality. Findings show pathways to address inequities, including early linkage to care for mental health and opioid use disorders. This analysis shows the use of comprehensive socioecologic data to identify the precursors to fatal overdoses, which could allow earlier intervention and reallocation of resources in high-risk communities.

Medicaid participation among practitioners authorized to prescribe buprenorphine.

INTRODUCTION: This study examines Medicaid participation among buprenorphine waivered providers in Virginia in 2019, with a particular focus on the prescribing differences between different physician specialties, nurse practitioners and physicians assistants (NP and PA). METHODS: Secondary data sources include the 2019 DEA list of buprenorphine waivered prescribers, Virginia Medicaid claims for buprenorphine, physician characteristics from the Virginia Department of Health Professions, SAMHSA Behavioral Treatment Services Locator, and area level characteristics. This cross-sectional study is based on a linkage of Medicaid claims data to a list of Virginia practitioners authorized to prescribe buprenorphine in 2019. Using a two-part logistic regression, we assess prescriber license type and local area factors that are associated with: (1) the probability of prescribing buprenorphine to any Medicaid patients in 2019; (2) the number of Medicaid patients treated by each prescriber in 2019. RESULTS: Adjusted odds ratios show that nurse practitioners with buprenorphine waivers are more likely to treat any Medicaid patients compared to physicians (odds ratio (OR), 2.016; p = 0.000). Among prescribers who treated any Medicaid patients, the probability of treating a large number of Medicaid patients was higher among nurse practitioners relative to physicians (OR, 2.869, p = 0.002). Medicaid participation was much higher among prescribers with patient limits of 100 and 275 compared to prescribers with patient limits of 30 (OR, 6.66, p = 0.000 and 29.40, p = 0.000, respectively). CONCLUSIONS: State Medicaid programs have been at the forefront of addressing their state's opioid epidemic, including expanding access to buprenorphine treatment. This study provides evidence that targeted outreach efforts should include NP license types as well as physicians, and is consistent with prior studies showing that NP are especially important in filling treatment gaps for underserved areas and populations.

Hospital Use Declines After Implementation Of Virginia Medicaid's Addiction And Recovery Treatment Services.

Medicaid programs responded to the opioid crisis by expanding treatment coverage and reforming delivery systems. We assessed whether Virginia's Addiction and Recovery Treatment Services (ARTS) program, implemented in April 2017, influenced emergency department and inpatient use. Using claims for January 2016-June 2018 and difference-in-differences models, we compared beneficiaries with opioid use disorder before and after ARTS implementation to beneficiaries with no substance use disorder. After program implementation, the likelihood of having an emergency department visit in a quarter declined by 9.4 percentage points (a 21.1 percent relative decrease) among beneficiaries with opioid use disorder, compared to 0.9 percentage points among beneficiaries with no substance use disorder. Similarly, the likelihood of having an inpatient hospitalization declined among beneficiaries with opioid use disorder. In contrast to other states, Virginia has a new Medicaid expansion population whose beneficiaries enter a delivery system in which reforms of the addiction treatment system are well under way.

Group leaders establish cooperative norms that persist in subsequent interactions.

The temptation to free-ride on others' contributions to public goods makes enhancing cooperation a critical challenge. Solutions to the cooperation problem have centered on installing a sanctioning institution where all can punish all, i.e., peer punishment. But a new, growing literature considers whether and when the designation of a group leader-one group member, given the sole ability to administer punishment-is an effective and efficient alternative. What remains unknown is whether and to what extent these group leaders establish cooperative norms in their groups via their own contributions to the public good, their use of sanctions, or both. Nor has past work examined whether leaders' behaviors have lasting effects on non-leaders' cooperation in subsequent interactions, outside of the leader's purview. Here I show that leaders' contributions to the public good predict non-leaders' subsequent cooperation. Importantly, the effect is not limited to cooperation within the institution: the effect of leaders' contributions continue to predict non-leaders' contributions in a later interaction, where sanctions are removed. This process is mediated by non-leaders' increased contributions in the institution, suggesting that leaders have effects on followers that shape followers' subsequent behaviors. These effects occur above and beyond a baseline tendency to be influenced by non-leader group members; they also occur above and beyond the influence of peers in groups under a peer punishment institution. Results underscore how critical it is that groups install cooperative leaders: followers model their leaders' cooperation choices, even in decisions external to the original institution and outside of the leader's watch.

The strength of dynamic ties: The ability to alter some ties promotes cooperation in those that cannot be altered.

Dynamic networks, where ties can be shed and new ties can be formed, promote the evolution of cooperation. Yet, past research has only compared networks where all ties can be severed to those where none can, confounding the benefits of fully dynamic networks with the presence of some dynamic ties within the network. Further, humans do not live in fully dynamic networks. Instead, in real-world networks, some ties are subject to change, while others are difficult to sever. Here, we consider whether and how cooperation evolves in networks containing both static and dynamic ties. We argue and find that the presence of dynamic ties in networks promotes cooperation even in static ties. Consistent with previous work demonstrating that cooperation cascades in networks, our results show that cooperation is enhanced in networks with both tie types because the higher rate of cooperation that occurs following the dynamics process "spills over" to those relations that are more difficult to alter. Thus, our findings demonstrate the critical role that dynamic ties play in promoting cooperation by altering behavioral outcomes even in non-dynamic relations.

The Enforcement of Moral Boundaries Promotes Cooperation and Prosocial Behavior in Groups.

The threat of free-riding makes the marshalling of cooperation from group members a fundamental challenge of social life. Where classical social science theory saw the enforcement of moral boundaries as a critical way by which group members regulate one another's self-interest and build cooperation, moral judgments have most often been studied as processes internal to individuals. Here we investigate how the interpersonal expression of positive and negative moral judgments encourages cooperation in groups and prosocial behavior between group members. In a laboratory experiment, groups whose members could make moral judgments achieved greater cooperation than groups with no capacity to sanction, levels comparable to those of groups featuring costly material sanctions. In addition, members of moral judgment groups subsequently showed more interpersonal trust, trustworthiness, and generosity than all other groups. These findings extend prior work on peer enforcement, highlighting how the enforcement of moral boundaries offers an efficient solution to cooperation problems and promotes prosocial behavior between group members.

Prosocial Orientation Alters Network Dynamics and Fosters Cooperation.

Dynamic networks have been shown to increase cooperation, but prior findings are compatible with two different mechanisms for the evolution of cooperation. It may be that dynamic networks promote cooperation even in networks composed entirely of egoists, who strategically cooperate to attract and maintain profitable interaction partners. Alternatively, drawing on recent insights into heterogeneous social preferences, we expect that dynamic networks will increase cooperation only when nodes are occupied by persons with more prosocial preferences, who tend to attract and keep more cooperative partners relative to egoists. Our experiment used a standard procedure to classify participants a priori as egoistic or prosocial and then embedded them in homogeneous networks of all prosocials or all egoists, or in heterogeneous networks (50/50). Participants then interacted in repeated prisoner's dilemma games with alters in both static and dynamic networks. In both heterogeneous and homogeneous networks, we find dynamic networks only promote cooperation among prosocials. Resulting from their greater cooperation, prosocials' relations are more stable, yielding substantially higher fitness compared to egoists in both heterogeneous and homogeneous dynamic networks. Our results suggest that a key to the evolution and stability of cooperation is the ability of those with prosocial preferences to alter their networks.