Assessment of Filled Buprenorphine Prescriptions for Opioid Use Disorder During the Coronavirus Disease 2019 Pandemic

This article is made available for unrestricted research re-use and secondary analysis in any form or by any means with acknowledgement of the original source. These permissions are granted for the duration of the World Health Organization (WHO) declaration of COVID-19 as a global pandemic.The coronavirus disease 2019 (COVID-19) pandemic has profoundly disrupted health care delivery in the US.1 The Centers for Disease Control and Prevention noted a 9.1% increase in reported 12-month counts of drug overdose deaths from March 2019 to March 2020, from 67 726 to 73 860.2 On March 13, 2020, a COVID-19 national emergency was declared. To diminish potential barriers to treatment access, 3 days later, federal guidelines on telemedicine use were released, providing authorized practitioners increased flexibility to prescribe buprenorphine to patients with opioid use disorder (OUD) during this public health emergency.3 Other local, state, and federal policy initiatives have also attempted to preserve access to medication treatment for OUD, yet the cumulative outcome of these undertakings is not clear

Essays on How Hospitals Responded to Pay for Performance Incentives

My dissertation analyzes the effects of changes in Medicare reimbursement policies. The specific payment change I analyze is the Hospital Readmissions Reduction Program (HRRP), which is a prominent Pay for Performance (P4P) policy that penalizes hospitals for excess readmissions. In a body of work , I study the consequences of this policy on hospital resource use and patient outcomes for illnesses that are an explicit focus of the P4P policy and for illnesses not explicitly specified by the policy. Empirically, in two chapters, I use two, complementary quasi-experimental research designs, regression kink and difference-in-differences, combined with data on the entire Medicare inpatient population. The first chapter, develops a theoretical model of hospital behavior and from this makes predictions about the effect of the HRRP on hospital inpatient spending highlighting the potential for the P4P plan to reallocate resources in both intended and unintended ways. This model guides the empirical analyses. First, I use a regression kink design to obtain estimates of the effect of the HRRP on readmissions and potential mechanisms that hospitals may use to reduce readmissions, such as spending on inpatient care, discharge destination and patient selection. I also examine the effect of the HRRP on mortality. Estimates indicate that hospitals penalized for excess heart attack (AMI) readmissions decreased AMI readmissions by 30% and increased spending on AMI patients by 40%. This additional care had no impact on mortality. Interestingly, I find that hospitals penalized for AMI readmissions increased the quantity of care for patients with diagnoses not targeted by the HRRP. Thus the P4P incentives of the HRRP did not cause hospitals to reallocate resources away from non-targeted conditions. Hospitals penalized for excess readmissions for pneumonia or heart failure did not appear to respond to the HRRP incentives. Interestingly, I demonstrate using the conceptual model, that as the number of patients in the targeted condition rises, the marginal cost of reducing the penalty increases by relatively more than the marginal benefit. Since HF and PN admit a relatively larger number of patients, this could increase the cost associated with amending the process of care and reducing readmissions for these conditions. The analysis in chapter 1, assumes that the treatment is equal to the HRRP penalty (or revenue reduction) experienced at the start of the HRRP program. With this assumption, the empirical analysis is well-suited for the regression-kink research design because the HRRP penalty is zero until it reaches a threshold and then grows linearly from zero at the threshold to a maximum penalty. In a second chapter, I assume that hospitals form expectations about the probability of being penalized based on the relationship between past hospital performance with respect to readmissions and the HRRP penalty at the start of the program. In this approach, some hospitals that were not penalized at the start of the program still have a positive expectation of being penalized in the future. I use this expected penalty to define the treatment due to the HRRP and execute a difference in differences design to estimate the HRRP effects on all Medicare hospitals.I find the largest reduction in readmissions due to the HRRP to be for AMI (heart attack) patients. Specifically, hospitals reduced AMI readmission rates commensurately with expectations of future penalties. I find that only hospitals with the highest expected penalties reduced HF and PN readmissions. I also find evidence that hospitals focused the reductions in readmissions towards the condition with the highest share of the penalty. That is, hospitals mainly penalized due to AMI readmissions, intensified the response on AMI patients and did not reduce PN and HF readmissions

Racial and Ethnic Disparities in Buprenorphine and Extended-Release Naltrexone Filled Prescriptions During the COVID-19 Pandemic

Importance: COVID-19 disrupted delivery of buprenorphine and naltrexone treatment for opioid use disorder (OUD), and during the pandemic, members of racial and ethnic minority groups experienced increased COVID-19 and opioid overdose risks compared with White individuals. However, whether filled buprenorphine and naltrexone prescriptions varied across racial and ethnic groups during the COVID-19 pandemic remains unknown. Objective: To investigate whether disruptions in filled buprenorphine and naltrexone prescriptions differed by race and ethnicity and insurance status or payer type. Design, setting, and participants: This cross-sectional study used retail pharmacy claims from May 2019 to June 2021 from the Symphony Health database, which includes 92% of US retail pharmacy claims, with race and ethnicity data spanning all insurance status and payer categories. Interrupted time series were used to estimate levels and trends of dispensed buprenorphine and naltrexone prescriptions before and after pandemic onset. Included individuals were those who filled buprenorphine and extended-release naltrexone prescriptions. Data were analyzed from July 2021 through March 2022. Main outcomes and measures: Weekly rates of dispensed buprenorphine and extended-release naltrexone prescription fills per 1000 patients and proportion of longer (ie, ≥14 days' supply) buprenorphine prescription fills were calculated. Analyses were stratified by patient race and ethnicity and further by insurance status and payer type for White and Black patients. Results: A total of 1 556 860 individuals who filled buprenorphine prescriptions (4359 Asian [0.3%], 94 657 Black [6.1%], 55 369 Hispanic [3.6%], and 664 779 White [42.7%]) and 127 506 individuals who filled extended-release naltrexone prescriptions (344 Asian [0.3%], 8186 Black [6.4%], 5343 Hispanic [4.2%], and 53 068 White [41.6%]) from May 6, 2019, to June 5, 2021, were analyzed. Prepandemic increases in buprenorphine fill rate flattened for all groups after COVID-19 onset (30.5 percentage point difference in trend; P < .001) compared with prepandemic trends. Significant level decreases in buprenorphine fills (ranging from 2.5% for Black patients; P = .009 to 4.0% for Hispanic patients; P = .009) at pandemic onset were observed for members of racial and ethnic minority groups but not White patients. At pandemic onset, rate of buprenorphine fills decreased in level for Medicare and cash-paying patients but with greater decreases for Black patients (Medicare: 10.0%; P < .001; cash: 20.0%; P < .001) than White patients (Medicare: 3.5%; P = .004; cash: 15.0%; P < .001). No decreases were found among Medicaid patients. Unlike buprenorphine, extended-release naltrexone had uniform level (from 10.0% for White patients with private insurance; P < .001 to 23.3% for Black patients with Medicare; P < .001) and trend (from 15.5 percentage points for White patients with Medicaid; P = .001 to 52.0 percentage points for Black patients with private insurance; P < .001) decreases across groups. Conclusions and relevance: This study found that the COVID-19 pandemic was associated with immediate decreases in filled buprenorphine prescriptions by members of racial and ethnic minority groups but not White individuals. These findings suggest that members of racial and ethnic minority groups had larger losses in buprenorphine access during the pandemic across payer types

Assessment of Filled Buprenorphine Prescriptions for Opioid Use Disorder During the Coronavirus Disease 2019 Pandemic

This article is made available for unrestricted research re-use and secondary analysis in any form or by any means with acknowledgement of the original source. These permissions are granted for the duration of the World Health Organization (WHO) declaration of COVID-19 as a global pandemic.The coronavirus disease 2019 (COVID-19) pandemic has profoundly disrupted health care delivery in the US.1 The Centers for Disease Control and Prevention noted a 9.1% increase in reported 12-month counts of drug overdose deaths from March 2019 to March 2020, from 67 726 to 73 860.2 On March 13, 2020, a COVID-19 national emergency was declared. To diminish potential barriers to treatment access, 3 days later, federal guidelines on telemedicine use were released, providing authorized practitioners increased flexibility to prescribe buprenorphine to patients with opioid use disorder (OUD) during this public health emergency.3 Other local, state, and federal policy initiatives have also attempted to preserve access to medication treatment for OUD, yet the cumulative outcome of these undertakings is not clear