Melinda Beeuwkes Buntin

Implementation Of Prescription Drug Monitoring Programs Associated With Reductions In Opioid-Related Death Rates

Over the past two decades the number of opioid pain relievers sold in the United States rose dramatically. This rise in sales was accompanied by an increase in opioid-related overdose deaths. In response, forty-nine states (all but Missouri) created prescription drug monitoring programs to detect high-risk prescribing and patient behaviors. Our objectives were to determine whether the implementation or particular characteristics of the programs were effective in reducing opioid-related overdose deaths. In adjusted analyses we found that a states implementation of a program was associated with an average reduction of 1.12 opioid-related overdose deaths per 100,000 population in the year after implementation. Additionally, states whose programs had robust characteristics-including monitoring greater numbers of drugs with abuse potential and updating their data at least weekly-had greater reductions in deaths, compared to states whose programs did not have these characteristics. We estimate that if Missouri adopted a prescription drug monitoring program and other states enhanced their programs with robust features, there would be more than 600 fewer overdose deaths nationwide in 2016, preventing approximately two deaths each day.

Toward a science of learning systems: a research agenda for the high-functioning Learning Health System

Objective The capability to share data, and harness its potential to generate knowledge rapidly and inform decisions, can have transformative effects that improve health. The infrastructure to achieve this goal at scale—marrying technology, process, and policy—is commonly referred to as the Learning Health System (LHS). Achieving an LHS raises numerous scientific challenges. Materials and methods The National Science Foundation convened an invitational workshop to identify the fundamental scientific and engineering research challenges to achieving a national-scale LHS. The workshop was planned by a 12-member committee and ultimately engaged 45 prominent researchers spanning multiple disciplines over 2 days in Washington, DC on 11–12 April 2013. Results The workshop participants collectively identified 106 research questions organized around four system-level requirements that a high-functioning LHS must satisfy. The workshop participants also identified a new cross-disciplinary integrative science of cyber-social ecosystems that will be required to address these challenges. Conclusions The intellectual merit and potential broad impacts of the innovations that will be driven by investments in an LHS are of great potential significance. The specific research questions that emerged from the workshop, alongside the potential for diverse communities to assemble to address them through a ‘new science of learning systems’, create an important agenda for informatics and related disciplines.

Social Risk Factors and Equity in Medicare Payment.

A new National Academies report outlines social risk factors that should be accounted for in quality-measurement and payment systems, recommending ways to promote fairness for providers while enhancing incentives to improve care for disadvantaged patients.

Did the medicare inpatient rehabilitation facility prospective payment system result in changes in relative patient severity and relative resource use

Background:The Centers for Medicare and Medicaid Services implemented a prospective payment system (PPS) in 2002 for care provided by inpatient rehabilitation facilities (IRFs) to Medicare beneficiaries. Objective:We sought to examine changes in the composition of Medicare beneficiaries in IRFs by examining the percentages of patients having worse functional or health status than the average for their payment groups (relative severity) and of patients having greater cost or longer length of stay than the average for their payment groups (relative resource use) before versus after IRF PPS; to examine whether observed changes in relative resource use were expected given predicted changes; and to explore whether these effects varied by IRF Medicare volume. Methods:In an observational study of indicators of Medicare beneficiary relative severity and relative resource use, we studied cases paid for by Medicare during 1999 and 2002 having an acute care stay preceding their IRF stay (n = 363,542 in 1999 and 446,002 in 2002). Results:Similar percentages of cases had longer than expected lengths of stay, greater-than-expected costs per case, and worse-than-expected functional status pre- versus post-IRF PPS. Cases under the IRF PPS had lower predicted probabilities of death 150 days after admission. Although predicted relative resource use remained steady, observed relative resource use decreased after IRF PPS. Conclusions:IRF patient composition has not changed meaningfully for Medicare beneficiaries, but patients within payment groups are being provided less care, which could be attributable to the IRF PPS, existing trends in decreasing length of stay, or both.

Surgeon Participation in Early Accountable Care Organizations

Objective: We aimed to characterize the landscape of surgeon participation in early accountable care organizations (ACOs) and to identify specialty-, organization-, and market-specific factors associated with ACO participation. Background: Despite rapid deployment of alternative payment models (APMs), little is known about the prevalence of surgeon participation, and key drivers behind surgeon participation in APMs. Methods: Using data from SK&A, a research firm, we evaluated the near universe of US practices to characterize ACO participation among 125,425 US surgeons in 2015. We fit multivariable logistic regression models to characterize key drivers of ACO participation, and more specifically, the interaction between ACO affiliation and organizational structure. Results: Of 125,425 US surgeons, 27,956 (22.3%) participated in at least 1 ACO program in 2015. We observed heterogeneity in participation by subspecialty, with trauma and transplant reporting the highest rate of ACO enrollment (36% for both) and plastic surgeons reporting the lowest (12.9%) followed by ophthalmology (16.0%) and hand (18.6%). Surgeons in group practices and integrated systems were more likely to participate relative to those practicing independently (aOR 1.57, 95% CI 1.50, 1.64; aOR 4.87, 95% CI 4.68, 5.07, respectively). We observed a statistically significant interaction (P <0.001) between surgical specialty and practice organization. Model-derived predicted probabilities revealed that, within each specialty, surgeons in integrated health systems had the highest predicted probabilities of ACO and those practicing independently generally had the lowest. Conclusions: We observed considerable variation in ACO enrollment among US surgeons, mediated at least in part by differences in practice organization. These data underscore the need for development of frameworks to characterize the strategic advantages and disadvantages associated with APM participation.

Anticipating the Unintended Consequences of Closing the Door on Physician Self-Referral

PURPOSE While physician self-referral has been associated with increased health care use, the downstream effects of the practice remain poorly characterized. Accordingly we identified the relationship between urologist self-referral and downstream health care use in patients with urinary stone disease. MATERIALS AND METHODS With urologist self-referral status as the exposure of interest, we performed a retrospective cohort study of Medicare beneficiaries from 2008 to 2010 to evaluate the relationship between self-referral and imaging intensity, risk of surgical treatment and time to surgical treatment for urinary stone disease. RESULTS We identified dose dependent increases in computerized tomography use with increasing stratum of urologist self-referral. Compared to nonself-referring urologists, computerized tomography use was 1.19 times higher (95% CI 1.07-1.34) in episodes ascribed to intermediate frequency (5 to 9) and 1.32 times higher (95% CI 1.16-1.50) in episodes ascribed to high frequency (10+) self-referring urologists. Self-referral was inversely associated with risk of surgical treatment for stone disease. Specifically, patients treated by intermediate and high frequency self-referring urologists were less likely to undergo surgical treatment than those treated by nonself-referring urologists, with HR 0.84 (95% CI 0.71-0.99) and HR 0.81 (95% CI 0.66-0.99), respectively. We identified no statistically significant between-group differences in time to surgical treatment. CONCLUSIONS Self-referral is associated with increased use of computerized tomography and with decreased use of surgery for stone disease. While policy efforts to further restrict physician self-referral may reduce the use of computerized tomography, they may also result in unintended consequences with respect to patterns of surgical care.

Diversity of Participants in the 340B Drug Pricing Program for US Hospitals

increasing overall rates of prophylaxis rather than overall appropriateness. Although overall rates have improved, the unintended consequence may be excess administration of VTE prophylaxis among low-risk patients. The major drawback to pharmacologic overprophylaxis is major bleeding.5 Patient discomfort, potential risk of falls and impaired mobility with mechanical prophylaxis, medication cost, and risk for heparin-induced thrombocytopenia are additional concerns. Limitations of this study include its observational design subject to inherent biases. Furthermore, this analysis did not incorporate VTE events, so it is unknown whether 1 specific VTE prophylaxis strategy was superior to another. After years of promoting aggressive VTE prophylaxis strategies for hospitalized patients, renewed effort to scale back—or “deimplement”—this practice in low-risk patients may be necessary.6 Discontinuing conventional practices, however, can be difficult, even in the presence of newer compelling data.

Medicare Accountable Care Organization Enrollment and Appropriateness of Cancer Screening

Importance Despite rapid diffusion of Accountable Care Organizations (ACOs), whether ACO enrollment results in observable changes in cancer screening remains unknown. Objective To determine whether Medicare Shared Savings Program (MSSP) ACO enrollment changes the appropriateness of screening for breast, colorectal, and prostate cancers. Design, Setting, and Participants For this population-based analysis of Medicare beneficiaries, we used Medicare data from 2007 through 2014 and evaluated changes in screening associated with ACO enrollment using differences-in-differences (DD) analyses. We then performed difference-in-difference-in-differences (DDD) analyses to determine whether observed changes in cancer screening associated with ACO enrollment were different across strata of appropriateness, defined using age (65-74 years vs ≥75 years) and predicted survival (top vs bottom quartile). Main Outcomes and Measures Rates of breast, colorectal, and prostate cancer screening measured yearly as a proportion of eligible Medicare beneficiaries undergoing relevant screening services. Results Among Medicare beneficiaries, comprising 39 218 652 person-years before MSSP enrollment and 17 252 345 person-years after MSSP enrollment, breast cancer screening declined among both ACO (42.7% precontract, 38.1% postcontract) and non-ACO (37.3% precontract, 34.1% postcontract) populations. The adjusted rate of decline (DD) in the ACO population exceeded the non-ACO population by 0.79% (P < .001). This decline was most pronounced among elderly women (–2.1%), with minimal observed change among younger women (−0.26%). Baseline colorectal cancer screening rates were lower than those for breast cancer among both ACO (10.1% precontract, 10.3% postcontract) and non-ACO (9.2% precontract, 9.1% postcontract) populations. We observed an adjusted 0.24% (P = .03) increase in screening associated with ACO enrollment, most pronounced among younger Medicare beneficiaries (0.36%). For breast and colorectal cancer, we observed statistically significant differences in estimates of effect between age strata, suggesting that the ACO effect on cancer screening is mediated by age (DDD for both P < .001). Prostate cancer screening declined among ACO (35.1% precontract, 28.5% postcontract) and non-ACO (31.2% precontract, 25.7% postcontract) populations. The adjusted rate of decline in the ACO population exceeded that of the non-ACO population by 1.2%. We observed no difference in estimate of effect between age strata, suggesting that the ACO-mediated changes in prostate cancer screening are similar among younger and elderly men. Results characterizing appropriateness with predicted survival mirrored those when stratified by age. Conclusions and Relevance Medicare Shared Savings Program ACO enrollment is associated with more appropriate breast and colorectal screening, although the magnitude of the observed ACO effect is modest in the early ACO experience.

Physician Competition in the Era of Accountable Care Organizations

OBJECTIVE To calculate physician concentration levels for all U.S. markets using detailed data on integration and accountable care organization (ACO) participation. DATA SOURCE 2015 SK&A office-based physician survey linked to all commercial and public payer ACOs. STUDY DESIGN We construct three separate Herfindahl-Hirschman Index (HHI) measures and plot their distributions. We then investigate how prevailing levels of concentration change when incorporating more detailed organizational features into the HHI measure. PRINCIPAL FINDINGS Horizontal and vertical integration strongly influences measures of physician concentration; however, ACOs have limited impact overall. ACOs are often present in competitive markets, and only in a minority of these markets do ACOs substantively increase physician concentration. CONCLUSIONS Monitoring ACO effects on physician competition will likely have to proceed on a case-by-case basis.

Barriers to accessing treatment for pregnant women with opioid use disorder in Appalachian states

Abstract Background and aims: Opioid agonist therapies (OATs) are highly effective treatments for opioid use disorders (OUDs), especially for pregnant women; thus, improving access to OAT is an urgent public policy goal. Our objective was to determine if insurance and pregnancy status were barriers to obtaining access to OAT in 4 Appalachian states disproportionately impacted by the opioid epidemic. Methods: Between April and May 2017, we conducted phone surveys of OAT providers, opioid treatment programs (OTPs), and outpatient buprenorphine providers, in Kentucky, North Carolina, Tennessee, and West Virginia. Survey response rates were 59%. Logistic models for dichotomous outcomes (e.g., patient acceptance) and negative binomial models were created for count variables (e.g., wait time), overall and for pregnant women. Results: The majority of OAT providers were accepting new patients; however, providers were less likely to treat pregnant women (91% vs. 75%; p < .01). OTPs were more likely to accept new patients than waivered buprenorphine providers (97% vs. 83%; p = .01); rates of accepting pregnant patients were lower in both (91% and 53%; p < .01). OTPs and buprenorphine providers accepted cash payments for services at high rates (OTP: 100%; buprenorphine: 89.4%; p < .01); Medicaid and private insurance were accepted at lower rates. In adjusted models, providers were less likely to accept pregnant women if they took any insurance (adjusted odds ratio [aOR] = 0.15, 95% confidence interval [CI]: 0.03–0.68) or were a buprenorphine provider (aOR = 0.09, 95% CI: 0.02–0.37). Conclusions: We found that OAT providers frequently did not accept any insurance and frequently did not treat pregnant women in an area of the country disproportionately affected by the opioid epidemic. Policymakers could prioritize improvements in provider training (e.g., training of obstetricians to become buprenorphine prescribers) as a means to enhance access to pregnant women or enhancing reimbursement rates as a means of improving insurance acceptance for OAT.