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2019
Austin Frakt and Ateev Mehrotra. 2019. “What Type of Price Transparency Do We Need in Health Care?” Ann Intern Med, 170, 8, Pp. 561-562.
Austin Frakt and Ateev Mehrotra. 2019. “What Type of Price Transparency Do We Need in Health Care?” Ann Intern Med, 170, 8, Pp. 561-562.
Anna D Sinaiko, Shehnaz Alidina, and Ateev Mehrotra. 2019. “Why aren't more employers implementing reference-based pricing benefit design?” Am J Manag Care, 25, 2, Pp. 85-88.Abstract
OBJECTIVES: There is robust evidence that implementation of reference-based pricing (RBP) benefit design decreases spending. This paper investigates employer adoption of RBP as a strategy to improve the value of patients' healthcare choices, as well as facilitators and barriers to the adoption of RBP by employers. STUDY DESIGN: We conducted a qualitative study using 12 in-depth interviews with human resources executives or their representatives at large- or medium-sized self-insured employers. METHODS: Interviews were conducted and recorded over the phone between March 2017 and May 2017. Interviewees were asked about their adoption of RBP and facilitators and barriers to adoption. We applied thematic analysis to the transcripts. RESULTS: Despite broad employer awareness of RBP's potential for cost savings, few employers are including RBP in their benefit design. The major barriers to RBP adoption were the complexity of RBP benefit design, concern that employees could face catastrophic out-of-pocket costs, lack of a business case for implementation, and concern that RBP could hurt the employer's competitiveness in the labor market. The few employers that have adopted RBP have implemented extensive, year-round employee education campaigns and invested in multipronged and proactive decision support to help employees navigate their choices. CONCLUSIONS: Unless several fundamental barriers are addressed, uptake of RBP will likely continue to be low. Our findings suggest that simplifying benefit design, providing employees protection against very high out-of-pocket costs, understanding which decision-support strategies are most effective, and enhancing the business case could facilitate wider employer adoption of RBP.
Ray KN, Shi Z, Gidengil CA, Poon SJ, Uscher-Pines L, and Mehrotra A. 2019. “Antibiotic Prescribing During Pediatric Direct-to-Consumer Telemedicine Visits.” Pediatrics , 143, 5, Pp. e20190631.Abstract

BACKGROUND AND OBJECTIVES:

Use of commercial direct-to-consumer (DTC) telemedicine outside of the pediatric medical home is increasing among children, and acute respiratory infections (ARIs) are the most commonly diagnosed condition at DTC telemedicine visits. Our objective was to compare the quality of antibiotic prescribing for ARIs among children across 3 settings: DTC telemedicine, urgent care, and the primary care provider (PCP) office.

METHODS:

In a retrospective cohort study using 2015-2016 claims data from a large national commercial health plan, we identified ARI visitsby children (0-17 years old), excluding visits with comorbidities that could affect antibiotic decisions. Visits were matched on age, sex, chronic medical complexity, state, rurality, health plan type, and ARI diagnosis category. Within the matched sample, we compared the percentage of ARI visits with any antibiotic prescribing and the percentage of ARI visits with guideline-concordant antibiotic management.

RESULTS:

There were 4604 DTC telemedicine, 38 408 urgent care, and 485 201 PCP visits for ARIs in the matched sample. Antibioticprescribing was higher for DTC telemedicine visits than for other settings (52% of DTC telemedicine visits versus 42% urgent care and 31% PCP visits; P < .001 for both comparisons). Guideline-concordant antibiotic management was lower at DTC telemedicine visits than at other settings (59% of DTC telemedicine visits versus 67% urgent care and 78% PCP visits; P < .001 for both comparisons).

CONCLUSIONS:

At DTC telemedicine visits, children with ARIs were more likely to receive antibiotics and less likely to receive guideline-concordant antibiotic management compared to children at PCP visits and urgent care visits.

2018
Huskamp HA, Busch AB, Souza J, Uscher-Pines L, Rose S, Wilcock A, Landon BE, and Mehrotra A. 12/2018. “How Is Telemedicine Being Used In Opioid And Other Substance Use Disorder Treatment?” Health Affairs , 37, 12, Pp. 1940-1947.Abstract
Only a small proportion of people with a substance use disorder (SUD) receive treatment. The shortage of SUD treatment providers, particularly in rural areas, is an important driver of this treatment gap. Telemedicine could be a means of expanding access to treatment. However, several key regulatory and reimbursement barriers to greater use of telemedicine for SUD (tele-SUD) exist, and both Congress and the states are considering or have recently passed legislation to address them. To inform these efforts, we describe how tele-SUD is being used. Using claims data for 2010-17 from a large commercial insurer, we identified characteristics of tele-SUD users and examined how tele-SUD is being used in conjunction with in-person SUD care. Despite a rapid increase in tele-SUD over the study period, we found low use rates overall, particularly relative to the growth in telemental health. Tele-SUD is primarily used to complement in-person care and is disproportionately used by those with relatively severe SUD. Given the severity of the opioid epidemic, low rates of tele-SUD use represent a missed opportunity. As tele-SUD becomes more available, it will be important to monitor closely which tele-SUD delivery models are being used and their impact on access and outcomes.
Shi Z, Mehrotra A, Gidengil C, Poon SJ, Uscher-Pines L, and Ray KN. 12/2018. “Quality of care for acute respiratory infections during direct-to-consumer telemedicine visits for adults.” Health Affairs , 37, 12, Pp. 2014-2023.Abstract
In direct-to-consumer telemedicine, physicians treat patients through real-time audiovisual conferencing for common conditions such as acuterespiratory infections. Early studies had mixed findings on the quality of care provided during direct-to-consumer telemedicine and were limited by small sample sizes and narrow geographic scopes. Using claims data for 2015-16 from a large national commercial insurer, we examined the quality of antibiotic management in adults with acute respiratory infection diagnoses at 38,839 direct-to-consumer telemedicinevisits, compared to the quality at 942,613 matched primary care visits and 186,016 matched urgent care visits. In the matched analyses, we found clinically similar rates of antibiotic use, broad-spectrum antibiotic use, and guideline-concordant antibiotic management. However, direct-to-consumer telemedicine visits had less appropriate streptococcal testing and a higher frequency of follow-up visits. These results suggest specific opportunities for improvement in direct-to-consumer telemedicine quality.
Barnett Ml, Ray KN, Souza J, and Mehrotra A. 11/27/2018. “Trends in Telemedicine Use in a Large Commercially Insured Population, 2005-2017.” JAMA Internal Medicine , 320, 20, Pp. 2147-2149.
Ezaz G, Leffler DA, Beach S, Schoen RE, Crockett SD, Gourevitch RA, Rose S, Morris M, Carrell DS, Greer JB, and Mehrotra A. 10/13/2018. “Association between endoscopist personality and rate of adenoma detection.” Clin Gastroenterol Hepatol, S1542-3565, 18, Pp. 31140-6.Abstract

BACKGROUND & AIMS:

There is significant variation among endoscopists in their adenoma detection rates (ADRs). We explored associations between ADR and characteristics of endoscopists, including personality traits and financial incentives.

METHODS:

We collected electronic health record data from October 2013 through September 2015 and calculated ADRs for physicians from 4 health systems. ADRs were risk-adjusted for differences in patient populations. Physicians were surveyed to assess financial motivations, knowledge and perceptions about colonoscopy quality, and personality traits. Of 140 physicians sent the survey, 117 responded.

RESULTS:

The median risk-adjusted ADR for all surveyed physicians was 29.3% (interquartile range, 24.1%-35.5%). We found no significant association between ADR and financial incentives, malpractice concerns, or physicians' perceptions of ADR as a quality metric. ADR was associated with the degree of self-reported compulsiveness relative to peers: among endoscopists who described themselves as much more compulsive, the ADR was 33.1%; among those who described themselves as somewhat more compulsive, the ADR was 32.9%; among those who described themselves as about the same as others, the ADR was 26.4%; and among those who described themselves as somewhat less compulsive, the ADR was 27.3%) (P = .0019). ADR also associated with perceived thoroughness (much more thorough than peers, ADR = 31.5%; somewhat more, 31.9%; same/somewhat less, 27.1%; P = .0173). Physicians who reported feeling rushed, having difficulty pacing themselves, or having difficulty in accomplishing goals had higher ADRs. A secondary analysis found the same associations between personality and adenomas per colonoscopy.

CONCLUSIONS:

In a survey of endoscopists and comparison of results with ADRs, we found no significant association between ADR and financial incentives, malpractice concerns, or perceptions of ADR as a quality metric. However, ADRs were higher among physicians who described themselves as more compulsive or thorough, and among those who reported feeling rushed or having difficulty accomplishing goals.

Kanagasingam Y, Xiao D, Vignarajan J, Preetham A, Tay-Kearney ML, and Mehrotra A. 9/7/2018. “Evaluation of Artificial Intelligence-Based Grading of Diabetic Retinopathy in Primary Care.” JAMA Netw Open , 1, 5, Pp. e182665.Abstract

IMPORTANCE:

There has been wide interest in using artificial intelligence (AI)-based grading of retinal images to identify diabetic retinopathy, but such a system has never been deployed and evaluated in clinical practice.

OBJECTIVE:

To describe the performance of an AI system for diabetic retinopathy deployed in a primary care practice.

DESIGN, SETTING, AND PARTICIPANTS:

Diagnostic study of patients with diabetes seen at a primary care practice with 4 physicians in Western Australia between December 1, 2016, and May 31, 2017. A total of 193 patients consented for the study and had retinal photographs taken of their eyes. Three hundred eighty-six images were evaluated by both the AI-based system and an ophthalmologist.

MAIN OUTCOMES AND MEASURES:

Sensitivity and specificity of the AI system compared with the gold standard of ophthalmologist evaluation.

RESULTS:

Of the 193 patients (93 [48%] female; mean [SD] age, 55 [17] years [range, 18-87 years]), the AI system judged 17 as having diabetic retinopathy of sufficient severity to require referral. The system correctly identified 2 patients with true disease and misclassified 15 as having disease (false-positives). The resulting specificity was 92% (95% CI, 87%-96%), and the positive predictive value was 12% (95% CI, 8%-18%). Many false-positives were driven by inadequate image quality (eg, dirty lens) and sheen reflections.

CONCLUSIONS AND RELEVANCE:

The results demonstrate both the potential and the challenges of using AI systems to identify diabeticretinopathy in clinical practice. Key challenges include the low incidence rate of disease and the related high false-positive rate as well as poor image quality. Further evaluations of AI systems in primary care are needed.

Ganguli I, Souza J, McWilliams JM, and Mehrotra A. 2/2018. “Practices Caring For The Underserved Are Less Likely To Adopt Medicare's Annual Wellness Visit.” Health Aff (Millwood), 37, 2, Pp. 283-291.Abstract
In 2011 Medicare introduced the annual wellness visit to help address the health risks of aging adults. The visit also offers primary care practices an opportunity to generate revenue, and may allow practices in accountable care organizations to attract healthier patients while stabilizing patient-practitioner assignments. However, uptake of the visit has been uneven. Using national Medicare data for the period 2008-15, we assessed practices' ability and motivation to adopt the visit. In 2015, 51.2 percent of practices provided no annual wellness visits (nonadopters), while 23.1 percent provided visits to at least a quarter of their eligible beneficiaries (adopters). Adopters replaced problem-based visits with annual wellness visits and saw increases in primary care revenue. Compared to nonadopters, adopters had more stable patient assignment and a slightly healthier patient mix. At the same time, visit rates were lower among practices caring for underserved populations (for example, racial minorities and those dually enrolled in Medicaid), potentially worsening disparities. Policy makers should consider ways to encourage uptake of the visit or other mechanisms to promote preventive care in underserved populations and the practices that serve them.
Felippe O Marcondes, Rebecca A Gourevitch, Robert E Schoen, Seth D Crockett, Michele Morris, and Ateev Mehrotra. 2018. “Adenoma Detection Rate Falls at the End of the Day in a Large Multi-site Sample.” Dig Dis Sci, 63, 4, Pp. 856-859.Abstract
BACKGROUND: There is concern that mental and physical fatigue among endoscopists over the course of the day will lead to lower adenoma detection rate (ADR). There are mixed findings in the prior literature on whether such an association exists. AIMS: The aim of this study was to measure the association between the number of colonoscopies performed in a day and ADR and withdrawal time. METHODS: We analyzed 86,624 colonoscopy and associated pathology reports between October 2013 and September 2015 from 131 physicians at two medical centers. A previously validated natural language processing program was used to abstract relevant data. We identified the order of colonoscopies performed in the physicians' schedule and calculated the ADR and withdrawal time for each colonoscopy position. RESULTS: The ADR for our overall sample was 29.9 (CI 29.6-30.2). The ADR for colonoscopies performed at the 9th + position was significantly lower than those at the 1st-4th or 5th-8th position, 27.2 (CI 25.8-28.6) versus 29.9 (CI 29.5-30.3), 30.2 (CI 29.6-30.9), respectively. Withdrawal time steadily decreased by colonoscopy position going from 11.6 (CI 11.4-11.9) min for the 1st colonoscopy to 9.6 (8.9-10.3) min for the 9th colonoscopy. CONCLUSION: In our study population, ADR and withdrawal time decrease by roughly 7 and 20%, respectively, by the end of the day. Our results imply that rather than mental or physical fatigue, lower ADR at the end of the day might be driven by endoscopists rushing.
Eric T Roberts, Michael J McWilliams, Laura A Hatfield, Sule Gerovich, Michael E Chernew, Lauren G Gilstrap, and Ateev Mehrotra. 2018. “Changes in Health Care Use Associated With the Introduction of Hospital Global Budgets in Maryland.” JAMA Intern Med, 178, 2, Pp. 260-268.Abstract
IMPORTANCE: In 2014, the State of Maryland placed the majority of its hospitals under all-payer global budgets for inpatient, hospital outpatient, and emergency department care. Goals of the program included reducing unnecessary hospital utilization and encouraging greater use of primary care. OBJECTIVE: To compare changes in hospital and primary care use through the first 2 years of Maryland's hospital global budget program among fee-for-service Medicare beneficiaries in Maryland vs matched control areas. DESIGN, SETTING, AND PARTICIPANTS: We matched 8 Maryland counties (94 967 beneficiaries) with hospitals in the program to 27 non-Maryland control counties (206 389 beneficiaries). Using difference-in-differences analysis, we compared changes in hospital and primary care use in Maryland vs the control counties from before (2009-2013) to after (2014-2015) the payment change, using 2 different assumptions. First, we assumed that preintervention differences between Maryland and the control counties would have remained constant past 2014 had Maryland not implemented global budgets (parallel trend assumption). Second, we assumed that differences in preintervention trends would have continued without the payment change (differential trend assumption). MAIN OUTCOMES AND MEASURES: Hospital stays (defined as admissions and observation stays); return hospital stays within 30 days of a prior hospital stay; emergency department visits that did not result in admission; price-standardized hospital outpatient department (HOPD) utilization; and visits with primary care physicians (overall and within 7 days of a hospital stay). RESULTS: We matched 8 Maryland counties with hospitals in the program (94 967 beneficiaries; 41.8% male; mean [SD] age, 72.3 [12.2] years) to 27 non-Maryland control counties (206 389 beneficiaries; 42.8% male; mean [SD] age, 71.7 [12.5] years). Assuming parallel trends, we estimated a differential change in Maryland of -0.47 annual hospital stays per 100 beneficiaries (95% CI, -1.65 to 0.72; P = .43) from the preintervention period (2009-2013) to 2015, but assuming differential trends, we estimated a differential change in Maryland of -1.24 stays per 100 beneficiaries (95% CI, -2.46 to -0.02; P = .047). Assuming parallel trends, we found a significant increase in primary care visits (+10.6 annual visits/100 beneficiaries; 95% CI, 4.6 to 16.6 annual visits/100 beneficiaries; P = .001), but assuming differential trends, we found no change (-0.8 visits/100 beneficiaries; 95% CI, -10.6 to 9.0 visits/100 beneficiaries; P = .87). Comparing estimates with both trend assumptions, we found no consistent changes in emergency department visits, return hospital stays, HOPD use, or posthospitalization primary care visits associated with Maryland's program. CONCLUSIONS AND RELEVANCE: We did not find consistent evidence that Maryland's hospital global budget program was associated with reductions in hospital use or increases in primary care visits among fee-for-service Medicare beneficiaries after 2 years. Evaluations over longer periods should be pursued.
Dustin McEvoy, Michael L Barnett, Dean F Sittig, Skye Aaron, Ateev Mehrotra, and Adam Wright. 2018. “Changes in hospital bond ratings after the transition to a new electronic health record.” J Am Med Inform Assoc, 25, 5, Pp. 572-574.Abstract
OBJECTIVE: To assess the impact of electronic health record (EHR) implementation on hospital finances. MATERIALS AND METHODS: We analyzed the impact of EHR implementation on bond ratings and net income from service to patients (NISP) at 32 hospitals that recently implemented a new EHR and a set of controls. RESULTS: After implementing an EHR, 7 hospitals had a bond downgrade, 7 had a bond upgrade, and 18 had no changes. There was no difference in the likelihood of bond rating changes or in changes to NISP following EHR go-live when compared to control hospitals. DISCUSSION: Most hospitals in our analysis saw no change in bond ratings following EHR go-live, with no significant differences observed between EHR implementation and control hospitals. There was also no apparent difference in NISP. CONCLUSIONS: Implementation of an EHR did not appear to have an impact on bond ratings at the hospitals in our analysis.
Eric T Roberts, Laura A Hatfield, Michael J McWilliams, Michael E Chernew, Nicolae Done, Sule Gerovich, Lauren Gilstrap, and Ateev Mehrotra. 2018. “Changes In Hospital Utilization Three Years Into Maryland's Global Budget Program For Rural Hospitals.” Health Aff (Millwood), 37, 4, Pp. 644-653.Abstract
In a substantial shift in payment policy, the State of Maryland implemented a global budget program for acute care hospitals in 2010. Goals of the program include controlling hospital use and spending. Eight rural hospitals entered the program in 2010, while urban and suburban hospitals joined in 2014. Prior analyses, which focused on urban and suburban hospitals, did not find consistent evidence that Maryland's program had contributed to changes in hospital use after two years. However, these studies were limited by short follow-up periods, may have failed to isolate impacts of Maryland's payment change from other state trends, and had limited generalizability to rural settings. To understand the effects of Maryland's global budget program on rural hospitals, we compared changes in hospital use among Medicare beneficiaries served by affected rural hospitals versus an in-state control population from before to after 2010. By 2013-three years after the rural program began-there were no differential changes in acute hospital use or price-standardized hospital spending among beneficiaries served by the affected hospitals, versus the within-state control group. Our results suggest that among Medicare beneficiaries, global budgets in rural Maryland hospitals did not reduce hospital use or price-standardized spending as policy makers had anticipated.
Xinke Zhang, Amelia Haviland, Ateev Mehrotra, Peter Huckfeldt, Zachary Wagner, and Neeraj Sood. 2018. “Does Enrollment in High-Deductible Health Plans Encourage Price Shopping?” Health Serv Res, 53 Suppl 1, Suppl Suppl 1, Pp. 2718-2734.Abstract
OBJECTIVE: To investigate whether enrollment in high-deductible health plans (HDHPs) led enrollees to choose lower-priced providers for office visits and laboratory tests. STUDY SETTING: Claims data from more than 40 large employers. STUDY DESIGN: We compared the change in price for office visits and laboratory tests for enrollees who switched to HDHPs versus enrollees who remained in traditional plans. We estimated separate models for enrollees who changed providers versus those who remained with the same provider to disentangle the effects of HDHPs on provider choice and negotiated prices. DATA COLLECTION: Claims data from 2004 to 2010 on 1.8 million enrollees. PRINCIPAL FINDINGS: After enrollment in HDHPs, 28 percent of enrollees changed physicians for office visits (compared to 19 percent in the Traditional Plan group, p < .01); however, this did not result in a statistically significant reduction in price for office visits. About 25 percent of enrollees changed providers for laboratory tests (compared to 23 percent in the Traditional Plan group, p < .01), resulting in savings of about $2.09 or a 12.8 percent reduction in price per laboratory test. We found that HDHPs had lower negotiated prices for office visits but not for laboratory tests. CONCLUSIONS: High-deductible health plan enrollment may shift enrollees to lower cost providers, resulting in modest savings.
Adam M Licurse and Ateev Mehrotra. 2018. “The Effect of Telehealth on Spending: Thinking Through the Numbers.” Ann Intern Med, 168, 10, Pp. 737-738.
Seth D Crockett, Rebecca A Gourevitch, Michele Morris, David S Carrell, Sherri Rose, Zhuo Shi, Julia B Greer, Robert E Schoen, and Ateev Mehrotra. 2018. “Endoscopist factors that influence serrated polyp detection: a multicenter study.” Endoscopy, 50, 10, Pp. 984-992.Abstract
BACKGROUND: Serrated polyps are important colorectal cancer precursors that are variably detected during colonoscopy. We measured serrated polyp detection rate (SPDR) in a large, multicenter, cross-sectional study of colonoscopy quality to identify drivers of SPDR variation. METHODS: Colonoscopy and pathology reports were collected for a 2-year period (10/2013-9/2015) from four sites across the United States. Data from reports, including size, location, and histology of polyps, were abstracted using a validated natural language processing algorithm. SPDR was defined as the proportion of colonoscopies with ≥ 1 serrated polyp (not including hyperplastic polyps). Multivariable logistic regression was performed to determine endoscopist characteristics associated with serrated polyp detection. RESULTS: A total of 104 618 colonoscopies were performed by 201 endoscopists who varied with respect to specialty (86 % were gastroenterologists), sex (18 % female), years in practice (range 1 - 51), and number of colonoscopies performed during the study period (range 30 - 2654). The overall mean SPDR was 5.1 % (SD 3.8 %, range 0 - 18.8 %). In multivariable analysis, gastroenterology specialty training (odds ratio [OR] 1.89, 95 % confidence interval [CI] 1.33 - 2.70), fewer years in practice (≤ 9 years vs. ≥ 27 years: OR 1.52, 95 %CI 1.14 - 2.04)], and higher procedure volumes (highest vs. lowest quartile: OR 1.77, 95 %CI 1.27 - 2.46)] were independently associated with serrated polyp detection. CONCLUSIONS: Gastroenterology specialization, more recent completion of training, and greater procedure volume are associated with serrated polyp detection. These findings imply that both repetition and training are likely to be important contributors to adequate detection of these important cancer precursors. Additional efforts to improve SPDR are needed.
Yogesan Kanagasingam, Di Xiao, Janardhan Vignarajan, Amita Preetham, Mei-Ling Tay-Kearney, and Ateev Mehrotra. 2018. “Evaluation of Artificial Intelligence-Based Grading of Diabetic Retinopathy in Primary Care.” JAMA Netw Open, 1, 5, Pp. e182665.Abstract
IMPORTANCE: There has been wide interest in using artificial intelligence (AI)-based grading of retinal images to identify diabetic retinopathy, but such a system has never been deployed and evaluated in clinical practice. OBJECTIVE: To describe the performance of an AI system for diabetic retinopathy deployed in a primary care practice. DESIGN, SETTING, AND PARTICIPANTS: Diagnostic study of patients with diabetes seen at a primary care practice with 4 physicians in Western Australia between December 1, 2016, and May 31, 2017. A total of 193 patients consented for the study and had retinal photographs taken of their eyes. Three hundred eighty-six images were evaluated by both the AI-based system and an ophthalmologist. MAIN OUTCOMES AND MEASURES: Sensitivity and specificity of the AI system compared with the gold standard of ophthalmologist evaluation. RESULTS: Of the 193 patients (93 [48%] female; mean [SD] age, 55 [17] years [range, 18-87 years]), the AI system judged 17 as having diabetic retinopathy of sufficient severity to require referral. The system correctly identified 2 patients with true disease and misclassified 15 as having disease (false-positives). The resulting specificity was 92% (95% CI, 87%-96%), and the positive predictive value was 12% (95% CI, 8%-18%). Many false-positives were driven by inadequate image quality (eg, dirty lens) and sheen reflections. CONCLUSIONS AND RELEVANCE: The results demonstrate both the potential and the challenges of using AI systems to identify diabetic retinopathy in clinical practice. Key challenges include the low incidence rate of disease and the related high false-positive rate as well as poor image quality. Further evaluations of AI systems in primary care are needed.
Michael L Barnett, Andrew R Olenski, Marcus N Thygeson, Denis Ishisaka, Salina Wong, Anupam B Jena, and Ateev Mehrotra. 2018. “A Health Plan's Formulary Led To Reduced Use Of Extended-Release Opioids But Did Not Lower Overall Opioid Use.” Health Aff (Millwood), 37, 9, Pp. 1509-1516.Abstract
Many insurers are using formulary design to influence opioid prescribing, but it is unclear if these changes lead to reduced use or just substitution between opioids. We evaluated the effect of a new prior authorization process implemented in July 2015 for extended-release (ER) oxycodone by Blue Shield of California. Compared to other commercially insured Californians, among 880,000 Blue Shield enrollees, there was a 36 percent drop in monthly rates of ER opioid initiation relative to control-group members, driven entirely by decreases in ER oxycodone initiation and without any substitution toward other ER opioids. This reduction was offset by a 1.4 percent relative increase in the rate of short-acting opioid fills. There was no significant change in the overall use of any opioids prescribed, measured as morphine milligram equivalents. This suggests that though insurers can play a meaningful role in reducing the prescribing of high-risk ER opioids, a formulary change focused on ER opioids alone is insufficient to decrease total opioid prescribing.
Haiden A Huskamp, Alisa B Busch, Jeffrey Souza, Lori Uscher-Pines, Sherri Rose, Andrew Wilcock, Bruce E Landon, and Ateev Mehrotra. 2018. “How Is Telemedicine Being Used In Opioid And Other Substance Use Disorder Treatment?” Health Aff (Millwood), 37, 12, Pp. 1940-1947.Abstract
Only a small proportion of people with a substance use disorder (SUD) receive treatment. The shortage of SUD treatment providers, particularly in rural areas, is an important driver of this treatment gap. Telemedicine could be a means of expanding access to treatment. However, several key regulatory and reimbursement barriers to greater use of telemedicine for SUD (tele-SUD) exist, and both Congress and the states are considering or have recently passed legislation to address them. To inform these efforts, we describe how tele-SUD is being used. Using claims data for 2010-17 from a large commercial insurer, we identified characteristics of tele-SUD users and examined how tele-SUD is being used in conjunction with in-person SUD care. Despite a rapid increase in tele-SUD over the study period, we found low use rates overall, particularly relative to the growth in telemental health. Tele-SUD is primarily used to complement in-person care and is disproportionately used by those with relatively severe SUD. Given the severity of the opioid epidemic, low rates of tele-SUD use represent a missed opportunity. As tele-SUD becomes more available, it will be important to monitor closely which tele-SUD delivery models are being used and their impact on access and outcomes.

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