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CORK Bibliography: Health Insurance

88 citations. 2009 to present

Prepared: June 2012

Aldridge AP; Kroutil LA; Cowell AJ; Reeves DB; Van Brunt DL. Medication costs to private insurers of diversion of medications for attention-deficit hyperactivity disorder. PharmacoEconomics 29(7): 621-635, 2011. (38 refs.)

Background: The diversion of prescription stimulants for misuse, particularly those used in the treatment of attention-deficit hyperactivity disorder (ADHD), is potentially a significant problem for public health and for healthcare funding and delivery. Most prior research on the diversion of prescription stimulants for misuse, particularly those used in the treatment of ADHD, has focused on the 'end users' of diverted medications rather than the suppliers. Furthermore, little is known about the direct costs of diversion for third-party insurance payers in the US. Objectives: The objectives of this study were to estimate the prevalence in the US of people whose private insurance paid costs for ADHD prescriptions that they gave or sold to another person (diversion), and to estimate medication costs of diversion to private insurers. Methods: Estimates are from a cross-sectional survey of respondents from two Internet survey panels targeting individuals aged 18-49 years in the civilian, noninstitutionalized US population, principally for those who filled prescriptions for ADHD medications in the past 30 days that were covered by private health insurance. Analysis weights were post-stratified to control totals from the Current Population Survey and National Health Interview Survey. Weighted prevalence rates and standard errors for diversion are reported, as are the costs of diverted pills using drug prices reported in the 2008 Thomson Reuters RED BOOK (TM). Sensitivity analyses were conducted that varied the cost assumptions for medications. Results: Among individuals aged 18-49 years whose private insurance paid some costs for ADHD medications in the past 30 days, 16.6% diverted medications from these prescriptions. Men aged 18-49 years for whom private insurance paid some costs of ADHD drugs in the past 30 days were more than twice as likely as their female counterparts to divert medications from these prescriptions (22.5% vs 9.1%; p = 0.03). After a pro-rated co-payment share was subtracted, the estimated value of diverted medications in a 30-day period was $US8.0 million. Lower- and upper-bound estimates were $US6.9 million to $US17 million, for a range of $US83 million to $US204 million annually. Overall, diversion accounted for about 3.6% of the total costs that private insurers paid for ADHD medications (range: 3.5-4.5%). The percentages varied by medication category, although relative differences were sensitive to inclusion of a pro-rated co-payment. A higher percentage of the costs of extended-release (XR) medications was lost to diversion compared with that for immediate-release (IR) medications. Conclusions: Costs of ADHD medications paid for by private insurers that were lost to diversion were small relative to the total estimated medication costs and relative to total estimated healthcare costs for treating ADHD. Nevertheless, there may be significant cost savings for insurers if diversion can be reduced, particularly for XR medications. These findings represent a first step to informing policies to reduce diversion both in the interest of public health and for direct and indirect cost savings to insurers.

Aseltine RH; DeMarco FJ; Wallenstein GV; Jacobs DG. Assessing barriers to change in drinking behavior: Results of an online employee screening program. Work: A Journal of Prevention, Assessment & Rehabilitation 32(2): 165-169, 2009. (20 refs.)

Background: The impact of alcohol abuse on worker productivity is considerable and appears to be increasing over time. Although early screening and intervention may help prevent or reduce the damaging health and productivity effects of problem drinking, barriers to behavioral change may render broad-based prevention efforts ineffectual. This study examined the correlates of two potential barriers to changes in drinking behavior - underestimation of drinking and lack of knowledge of helping resources - using data from web-based employee alcohol screenings. Methods: Anonymous screening data from 1185 employees of ten companies participating in the 2003 National Alcohol Screening Day were analyzed. The AUDIT, a 10-item screening instrument developed by the World Health Organization, was used to measure drinking behavior; employees' subjective assessments of their drinking were also obtained. Results: Over 53% of participants subjectively underestimated their drinking relative to their AUDIT results, and 58% of respondents did not know whether their medical insurance included benefits for alcohol treatment. Logistic regression analysis revealed that younger and male respondents tended to have the highest AUDIT scores and also ( along with married respondents) were most likely to underestimate their drinking. Younger, unmarried respondents were least likely to be aware of their alcohol treatment insurance benefits. Conclusions: Current corporate efforts to curtail problem drinking among employees may not adequately address barriers to change. Targeting at-risk employee groups for alcohol screening and dissemination of information about health insurance benefits and treatment options is recommended, as is providing personalized feedback based on screening results to raise awareness of at-risk drinking and available helping resources.

Bandi P; Cokkinides VE; Virgo KS; Ward EM. The receipt and utilization of effective clinical smoking cessation services in subgroups of the insured and uninsured populations in the U.S. Journal of Behavioral Health Services & Research 39(2): 202-213, 2012. (28 refs.)

Subgroups among the uninsured and even the insured may be at increased risk for not receiving and utilizing effective clinical smoking cessation services. Data for this study came from 18 to 64 year old smokers in the 2005 National Health Interview Survey. Long-term uninsured (greater than or equal to one year) smokers were less likely to receive physician advice to quit than those continuously-insured in the past year. Being long-term and short-term uninsured (less than one year) was negatively associated with dependence treatments' use in quit attempts compared to the continuously-insured, even though the prevalence of quit attempts were similar between these groups. Intermittent-uninsurance (spell of uninsurance in past year) did not influence cessation services delivery or use. Even though Medicaid-insured smokers were more likely to be advised to quit than those privately-insured, they were less likely to use dependence treatments, especially if they had a spell of uninsurance in the past year. Provisions in the Affordable Care Act of 2009 that ensure coverage of effective cessation services for previously-uninsured individuals and Medicaid-insured smokers may increase access and potentially improve population cessation rates.

Barry CL; Huskamp HA. Moving beyond parity - Mental health and addiction care under the ACA. (editorial). New England Journal of Medicine 365(11): 973-975, 2011. (5 refs.)

Barry CL; Huskamp HA; Goldman HH. A political history of federal mental health and addiction insurance parity. Milbank Quarterly 88(3): 404-433, 2010. (48 refs.)

Methods: Twenty-nine structured interviews were conducted with key informants in the federal parity debate, including members of Congress and their staff; lobbyists for consumer, provider, employer, and insurance groups; and other key contacts. Historical documentation, academic research on the effects of parity regulations, and public comment letters submitted to the U.S. Departments of Labor, Health and Human Services, and Treasury before the release of federal guidance also were examined. Findings: Three factors were instrumental to the passage of this law: the emergence of new evidence regarding the costs of parity, personal experience with mental illness and addiction, and the political strategies adopted by congressional champions in the Senate and House of Representatives. Conclusions: Challenges to implementing the federal parity policy warrant further consideration. This law raises new questions about the future direction of federal policymaking on behavioral health.

Baxter JD; Clark RE; Samnaliev M; Leung GY; Hashemi L. Factors associated with Medicaid patients' access to buprenorphine treatment. Journal of Substance Abuse Treatment 41(1): 88-96, 2011. (45 refs.)

Some studies have shown that patients entering buprenorphine treatment differ from those in other modalities. This study compares Massachusetts Medicaid beneficiaries who received buprenorphine, methadone or other treatment for opioid addiction in 2007. Patients' characteristics and comorbidities were identified through claims data, and associations between these factors and treatment type were investigated using multivariate analysis. Among patients receiving opioid agonist treatments, patients with prior buprenorphine treatment, HIV, bipolar disease, and other substance use disorders were more likely to receive buprenorphine treatment compared with methadone, whereas patients with heart failure, diabetes, hepatitis C, major depression, and anxiety were less likely to receive buprenorphine treatment. These differences may suggest variability in patient access, treatment preferences, and a need for different levels of services in different modalities. This information is important for understanding the impact of this new treatment in Medicaid populations and for developing treatment systems to best meet patients' needs.

Bloss G. The Alcohol Policy Information System (APIS) and policy research at NIAAA. (editorial). Alcohol Research & Health 34(2): 246-247, 2011. (14 refs.)

The Alcohol Policy Information System (APIS) (http://alcoholpolicy.niaaa.nih.gov) was created by the National Institute on Alcohol Abuse and Alcoholism (NIAAA) as a tool to facilitate research on the effects and effectiveness of alcohol-related public policies by providing authoritative, detailed, and comparable information on alcohol-related policies at the State and Federal levels in the United States. APIS data is based on primary legal research on the statutes and regulations through which policies are established. APIS provides detailed coverage for 35 specific policy topics organized in eight categories: 1) Underage Drinking (possession, consumption, purchase, sales, driving, false IDs); 2.) BAC (drivers, underage drivers, boaters); 3.) Transportation; 4.) Beverage Taxes; 5.) Retail Sales; 6.) Alcohol Control Systems; 7.) Pregnancy and Alcohol (warning signs during pregancy, criminal prosecution, treatment, child abuse and neglect; 8.) Health Care Services and Financing (insurance, losses attributed to intoxication, health insurance parity.) The coverage period for most topics begins January 1, 1998, and extends through January 1, 2010. Material is added quarterly.

Public Domain

Bouchery EE; Harwood HJ; Dilonardo J; Vandivort-Warren R. Type of health insurance and the substance abuse treatment gap. Journal of Substance Abuse Treatment 42(3): 289-300, 2012. (53 refs.)

Objective: Most individuals reporting symptoms consistent with substance use disorders do not receive care. This study examines the correlation between type of insurance coverage and receipt of substance abuse treatment, controlling for other observable factors that may influence treatment receipt. Method: Descriptive and multivariate analyses are conducted using pooled observations from the 2002-2007 editions of the National Survey on Drug Use and Health. The likelihood of treatment entry is estimated by type of insurance coverage controlling for personal characteristics and characteristics of the individual's substance use disorder. Results: Multivariate analyses that control for type of substance and severity of disorder (dependence vs. abuse) find that those with Civilian Health and Medical Program of the Uniformed Services/Veterans Affairs, Medicaid only, Medicare only, and Medicare and Medicaid (dual eligibles) have 50% to almost 90% greater odds of receiving treatment relative to those with private insurance. Conclusions: The privately insured population has substantially lower treatment entry rates than those with publicly provided insurance. Additional research is warranted to understand the source of the differences across insurance types so that improvements can be achieved.

Busch SH. Implications of the Mental Health Parity and Addiction Equity Act. (editorial). American Journal of Psychiatry 169(1): 1-3, 2012. (5 refs.)

Cannon MJ; Dominique Y; O'Leary LA; Sniezek JE; Floyd RL. Characteristics and behaviors of mothers who have a child with fetal alcohol syndrome. Neurotoxicology and Teratology 34(1): 90-95, 2012. (32 refs.)

Fetal alcohol syndrome (FAS) is a leading cause of birth defects and developmental disabilities. The objective of this study was to identify the characteristics and behaviors of mothers of children with FAS in the United States using population-based data from the FAS Surveillance Network (FASSNet). FASSNet used a multiple source methodology that identified FAS cases through passive reporting and active review of records from hospitals, specialty clinics, private physicians, early intervention programs, Medicaid, birth certificates and other vital records, birth defects surveillance programs, and hospital discharge data. The surveillance included children born during January 1, 1995-December 31, 1997. In the four states included in our analysis - Arizona, New York, Alaska, and Colorado - there were 257 confirmed cases and 96 probable cases for a total of 353 FAS cases. Compared to all mothers in the states where surveillance occurred, mothers of children with FAS were significantly more likely to be older, American Indians/Alaska Natives, Black, not Hispanic, unmarried, unemployed, and without prenatal care, to smoke during pregnancy, to have a lower educational level, and to have more live born children. A significant proportion of mothers (9-29%) had another child with suspected alcohol effects. Compared to all US mothers, they were also significantly more likely to be on public assistance, to be on Medicaid at their child's birth, to have received treatment for alcohol abuse, to have confirmed alcoholism, to have used marijuana or cocaine during pregnancy, to have their baby screen positive for alcohol or drugs at birth, to have had an induced abortion, to have had a history of mental illness, to have been involved in binge drinking during pregnancy, and to have drunk heavily (7 days/week) during pregnancy. These findings suggest that it is possible to identify women who are at high risk of having a child with FAS and target these women for interventions.

Center for Behavioral Health Statistics and Quality, Substance Abuse and Mental Health Services Administration. The N-SSATS Report. Acceptance of Private Health Insurance in Substance Abuse Treatment Facilities. (November 4, 2010). Rockville MD: Substance Abuse and Mental Health Administration, 2010. (5 refs.)

The National Survey of Substance Abuse Treatment Services (N-SSATS) is an annual census of all facilities in the United States, providing substance abuse treatment. Information collected includes the acceptance of various types of client payment including private health insurance as well as information on the type of treatment provided, the type of organization that operates the facility, and services offered. In 2008, a total of 13,688 substance abuse treatment facilities responded to N-SSATS. Of these, 539 (4 percent) provided free substance abuse treatment to all clients. Because these facilities did not accept any form of client payment, they are excluded from this analysis. Of the remaining facilities, nearly two thirds (65 percent) accepted private health insurance. [Note: With the recently enacted legislation on health insurance reform and parity in coverage of medical and behavioral health conditions, more people may be able to obtain health insurance that will cover some of the costs of substance abuse treatment services. ] The 2008 survey found that nearly two thirds (65%) of substance abuse treatment facilities accepted some private health insurance as a form of client payment. Facilities with a primary focus of providing mental health services (85%), general health care (82%), or a mix of mental health services and substance abuse treatment (78%) were more likely than facilities with a substance abuse treatment focus (56%) or other focus (37%) to accept private health insurance. Facilities that accepted private health insurance were more likely than those that did not to accept adolescents into treatment (58 vs. 33%). Facilities in urban areas were less likely than facilities in non-urban areas to accept private health insurance.

Public Domain

Cisneros GO; Douaihy AB; Kirisci L. Access to healthcare among injection drug users at a needle exchange program in Pittsburgh, PA. Journal of Addiction Medicine 3(2): 89-94, 2009. (7 refs.)

Objectives: The purpose of this study was to explore healthcare access among injection drug users (IDUs) at a needle exchange program in Pittsburgh, PA. Methods: A 2-page survey was conducted using a questionnaire adapted from a previous study, focusing on demographics, health characteristics, health service utilization, and healthcare satisfaction. Binary logistic regression analyses were performed to identify statistically significant associations between IDU characteristics and healthcare access. Results: Among 95 subjects surveyed, 48% were uninsured, 31%, reported having health conditions not followed by a physician, and 68% reported not seeing a physician regularly. The hospital emergency room was the site where most medical care was reportedly obtained. Twenty-three percent reported having problems as a result of not seeking needed medical care. The most commonly reported reason for not seeing a physician regularly was "financial." Young age and marriage/cohabitation were significantly associated with lacking health insurance (P < 0.005 and P < 0.05, respectively). Young age. uninsured Status, and non-white race were significantly associated with not seeing a physician regularly (P < 0.05. P < 0.005, and P < 0.05, respectively). Conclusion: The results Suggest that many IDUs at the needle exchange site have overall poor access to healthcare. Needle exchange programs May use the results of this Study to develop services that address uninsured status as a barrier to healthcare access and further improve the health of the IDU community.

Clark RE; Samnaliev M; McGovern MP. Impact of substance disorders on medical expenditures for medicaid beneficiaries with behavioral health disorders. Psychiatric Services 60(1): 35-42, 2009. (27 refs.)

Objective: This study measured the impact of substance use disorders on Medicaid expenditures for behavioral and physical health care among beneficiaries with behavioral health disorders. Methods: Claims for Medicaid beneficiaries with behavioral health diagnoses in 1999 from Arkansas, Colorado, Georgia, Indiana, New Jersey, and Washington were analyzed. Behavioral health and general medical expenditures for individuals with diagnoses of substance use disorders were compared with expenditures for those without such diagnoses. States were analyzed separately with adjustment for confounders. Results: A total of 148,457 beneficiaries met selection criteria, and 43,457 (29.3%) had a substance use diagnosis. Compared with other beneficiaries with behavioral health disorders, individuals with diagnoses of substance use disorders had significantly higher expenditures for physical health problems in five of six states. Approximately half of the additional care and expenditures were for treatment of physical conditions. Differences declined but remained statistically significant after adjustment for higher overall disease burden among beneficiaries with addictions. Medical expenditures for individuals with diagnoses of substance use disorders increased significantly with age in five of six states, whereas behavioral health expenditures were stable or declined. Hospital admissions for psychiatric and general medical reasons were higher for those with diagnoses of substance use disorders. Conclusions: The impact of addiction on Medicaid populations with behavioral health disorders is greater than the direct cost of mental health and addictions treatment. Higher medical expenditures can be partly attributed to greater prevalence of co-occurring physical disorders, but expenditures remained higher after adjustment for disease burden. Spending estimates based only on behavioral health diagnoses may significantly underestimate addictions-related costs, particularly for older adults.

Clark RE; Samnaliev M; Baxter JD; Leung GY. The evidence doesn't justify steps by state Medicaid programs to restrict opioid addiction treatment with buprenorphine. Health Affairs 30(8): 1425-1433, 2011. (23 refs.)

Many state Medicaid programs restrict access to buprenorphine, a prescription medication that relieves withdrawal symptoms for people addicted to heroin or other opiates. The reason is that officials fear that the drug is costlier or less safe than other therapies such as methadone. To find out if this is true, we compared spending, the use of services related to drug-use relapses, and mortality for 33,923 Massachusetts Medicaid beneficiaries receiving either buprenorphine, methadone, drug-free treatment, or no treatment during the period 2003-07. Buprenorphine appears to have significantly expanded access to treatment because the drug can be prescribed by a physician and taken at home compared with methadone, which by law must be administered at an approved clinic. Buprenorphine was associated with more relapse-related services but $1,330 lower mean annual spending than methadone when used for maintenance treatment. Mortality rates were similar for buprenorphine and methadone. By contrast, mortality rates were 75 percent higher among those receiving drug-free treatment, and more than twice as high among those receiving no treatment, compared to those receiving buprenorphine. The evidence does not support rationing buprenorphine to save money or ensure safety.

Clark RE; Weir S; Ouellette RA; Zhang JY; Baxter JD. Beyond health plans behavioral health disorders and quality of diabetes and asthma care for Medicaid beneficiaries. Medical Care 47(5): 545-552, 2009. (34 refs.)

Background: Most health insurance plans monitor ambulatory care quality using the Healthcare Effectiveness Data and Information Set (HEDIS), publicly reporting results at the plan level. Plan-level comparisons obscure the influence of patients served or settings where care is delivered. Mental illness, substance abuse, and other physical comorbidities, particularly prevalent among Medicaid beneficiaries, can impact adherence to recommended care. We analyzed individual-level HEDIS measures for diabetes and asthma from 5 Medicaid managed care plans to understand how these factors contribute to quality. Methods: We used claims and medical records to study HEDIS measures for persistent asthma (n = 9103) and diabetes (n = 1790) among beneficiaries enrolled in Massachusetts' Medicaid program during 2004 and 2005. Logistic regression models included patient-level demographic and health factors, provider type, region, and managed care plan. Results: Alcohol and drug use disorders and emergency department use were associated with lower quality care for most measures. Glycemic control was better for patients with diabetes and severe mental illness. Patients with higher illness burden and with more frequent ambulatory visits received higher quality care for both conditions. Younger adults received recommended care less often than older adults. Quality varied across plans. Conclusions: Additional efforts to improve quality of care for asthma and diabetes for Medicaid beneficiaries are needed for individuals with substance use disorders and young adults. Although evidence of higher quality for patients with multiple conditions is encouraging, improving quality for comparatively healthier individuals might also produce significant long-term benefits.

Collet TH; Salamin S; Zimmerli L; Kerr EA; Clair C; Picard-Kossovsky M et al. The quality of primary care in a country with universal health care coverage. Journal of General Internal Medicine 26(7): 724-730, 2011. (39 refs.)

BACKGROUND: Standard indicators of quality of care have been developed in the United States. Limited information exists about quality of care in countries with universal health care coverage. OBJECTIVE: To assess the quality of preventive care and care for cardiovascular risk factors in a country with universal health care coverage. DESIGN AND PARTICIPANTS: Retrospective cohort of a random sample of 1,002 patients aged 50-80 years followed for 2 years from all Swiss university primary care settings. MAIN MEASURES: We used indicators derived from RAND's Quality Assessment Tools. Each indicator was scored by dividing the number of episodes when recommended care was delivered by the number of times patients were eligible for indicators. Aggregate scores were calculated by taking into account the number of eligible patients for each indicator. KEY RESULTS: Overall, patients (44% women) received 69% of recommended preventive care, but rates differed by indicators. Indicators assessing annual blood pressure and weight measurements (both 95%) were more likely to be met than indicators assessing smoking cessation counseling (72%), breast (40%) and colon cancer screening (35%; all p < 0.001 for comparisons with blood pressure and weight measurements). Eighty-three percent of patients received the recommended care for cardiovascular risk factors, including > 75% for hypertension, dyslipidemia and diabetes. However, foot examination was performed only in 50% of patients with diabetes. Prevention indicators were more likely to be met in men (72.2% vs 65.3% in women, p < 0.001) and patients < 65 years (70.1% vs 68.0% in those a parts per thousand yen65 years, p = 0.047). CONCLUSIONS: Using standardized tools, these adults received 69% of recommended preventive care and 83% of care for cardiovascular risk factors in Switzerland, a country with universal coverage. Prevention indicator rates were lower for women and the elderly, and for cancer screening. Our study helps pave the way for targeted quality improvement initiatives and broader assessment of health care in Continental Europe.

Conover CJ; Weaver M; Arno P; Ang A; Ettner SL. Insurance coverage among people living with combined HIV/AIDS, chronic mental illness, and substance abuse disorders. Journal of Health Care for the Poor and Underserved 21(3): 1006-1030, 2010. (59 refs.)

HIV triply-diagnosed adults (those with chronic mental illness and substance abuse disorders) must rely heavily on public insurance to cover high annual medical costs (similar to $50,000). This study examines the nature and determinants of insurance coverage (including managed care) for this population, along with annual transitions in coverage. Relative to people living with HIV/AIDS in general, fewer triply-diagnosed adults rely on private coverage (3% vs. 30%), but their rate of being uninsured is only slightly lower (16% vs. 20%). More than one third of such adults below poverty are uninsured a matter of significant policy concern since the annual income of this group is less than 10% of the amount needed to cover their expected medical expenses. Those with the lowest mental health status were disproportionately represented in managed care. While coverage appears relatively stable over time, those with low incomes and moderate mental health status may face barriers in securing Medicaid.

Cowan B; Schwab B. The incidence of the healthcare costs of smoking. Journal of Health Economics 30(5): 1094-1102, 2011. (18 refs.)

Smokers earn less than non-smokers, but much is still unknown about the source(s) of the smoker's wage gap. We build on the work of Bhattacharya and Bundorf (2009), who provide evidence that obese workers receive lower wages on account of their higher expected healthcare costs. Similarly, we find that smokers who hold employer-sponsored health insurance (ESI) receive significantly lower wages than their nonsmoking peers, while smokers who are not insured through their employer endure no such wage penalty. Our results have two implications: first, the incidence of smokers' elevated medical costs appears to be borne by smokers themselves in the form of lower wages. Second, differences in healthcare costs between smokers and non-smokers are a significant source of the smoker's wage gap.

Crail J; Lahtinen A; Beck-Mannagetta J; Benzian H; Enmark B; Jenner T et al. Role and models for compensation of tobacco use prevention and cessation by oral health professionals. International Dental Journal 60(1): 73-79, 2010. (10 refs.)

Appropriate compensation of tobacco use prevention and cessation (TUPAC) would give oral health professionals better incentives to provide TUPAC, which is considered part of their professional and ethical responsibility and improves quality of care. Barriers for compensation are that tobacco addiction is not recognised as a chronic disease but rather as a behavioural disorder or merely as a risk factor for other diseases. TUPAC-related compensation should be available to oral health professionals, be in appropriate relation to other dental therapeutic interventions and should not be funded from existing oral health care budgets alone. We recommend modifying existing treatment and billing codes or creating new codes for TUPAC. Furthermore, we suggest a four-staged model for TUPAC compensation. Stages 1 and 2 are basic care, stage 3 is intermediate care and stage 4 is advanced care. Proceeding from stage 1 to other stages may happen immediately or over many years. Stage 1: Identification and documentation of tobacco use is part of each patient's medical history and included into oral examination with no extra compensation. Stage 2: Brief intervention consists of a motivational interview and providing information about existing support. This stage should be coded/reimbursed as a short preventive intervention similar to other advice for oral care. Stage 3: Intermediate care consists of a motivational interview, assessment of tobacco dependency, informing about possible support and pharmacotherapy, if appropriate. This stage should be coded as preventive intervention similar to an oral hygiene instruction. Stage 4: Advanced care. Treatment codes should be created for advanced interventions by oral health professionals with adequate qualification. Interventions should follow established guidelines and use the most cost-effective approaches.

de Preux LB. Anticipatory ex ante moral hazard and the effect of Medicare on prevention. Health Economics 20(9, special issue): 1056-1072, 2011. (31 refs.)

This paper extends the ex ante moral hazard model to allow healthy lifestyles to reduce the probability of illness in future periods, so that current preventive behaviour may be affected by anticipated changes in future insurance coverage. In the United States, Medicare is offered to almost all the population at the age of 65. We use nine waves of the US Health and Retirement Study to compare lifestyles before and after 65 of those insured and not insured pre 65. The double-robust approach, which combines propensity score and regression, is used to compare trends in lifestyle (physical activity, smoking, drinking) of the two groups before and after receiving Medicare, using both difference-in-differences and difference-in-differences-in-differences. There is no clear effect of the receipt of Medicare or its anticipation on alcohol consumption nor smoking behaviour, but the previously uninsured do reduce physical activity just before receiving Medicare.

Deck D; Wiitala W; McFarland B; Campbell K; Mullooly J; Krupski A et al. Medicaid coverage, methadone maintenance, and felony arrests: Outcomes of opiate treatment in two states. Journal of Addictive Diseases 28(2): 89-102, 2009. (52 refs.)

A modest number of clinics in Oregon and Washington provide MMT maintenance treatment (MMT) services. More than 10,000 clients in each state were followed for 3 years after an initial admission for opiate use between 1993 and 2000. Medicaid clients in both states had far greater access to MMT than their non-Medicaid counterparts, controlling for differences in client characteristics using propensity scores. Months in MMT were associated with much lower arrest rates than time not in treatment, but unexpectedly this was only true for clients participating in MMT for many months. Despite differences in the treatment systems for opiate addiction in these two states observed in previous studies, the current findings generalized across both states.

deGruy FV; Etz RS. Attending to the whole person in the patient-centered medical home: The case for incorporating mental healthcare, substance abuse care, and health behavior change. Families, Systems & Health 28(4): 298-307, 2010. (23 refs.)

The foundation of the U.S. healthcare system is faulty, and the consequences have become inescapable (Committee of Quality of Health Care in America, 2001). We are first among nations in spending on healthcare, whether measured in absolute dollars, per capita expenditures, or proportion of our national budget. Yet our citizens are the least healthy in the developed world. (Anderson & Hussey, 2001) Our nation's healthcare system is simply not a high-quality system. This shortfall is serious enough to cause tens of thousands of unnecessary deaths each year and to compromise our capacity for further economic growth (Anderson & Hussey, 2001; Anderson, Frogner, Johns, & Reinhardt, 2006; Macinko, Starfield, & Shi, 2003), yet it ramifies into so many of our political, financial, and social institutions that change is difficult and fraught with serious unintended consequences.

Dembe A; Wickizer T; Sieck C; Partridge J; Balchick R. Opioid use and dosing in the workers' compensation setting. A comparative review and new data from Ohio. American Journal of Industrial Medicine 55(4): 313-324, 2012. (38 refs.)

Background: Many authorities are concerned about the rising use and the potential overuse of opioid pain medications. A study of opioid prevalence and dosage in Ohio's workers' compensation (WC) system was conducted, with comparisons made to opioid use in other WC and non-WC settings. Methods: Systematic literature reviews of WC and non-WC opioid use and dosage nationally were conducted. Two years of Ohio WC data (2008-2009) were analyzed to determine average daily morphine equivalent dose (MED), opioid costs, pharmacies used per claimant, and extent of long-duration cases. Results: Nearly one-fifth (19.2%) of Ohio WC claims involved opioid use, compared to 31.8% in other WC systems and 17.9% in non-WC settings. Mean MED was 57.5 mg, compared to 47.8 mg in other WC systems, and 41.8 mg among non-WC populations. Nearly 10% of WC claims involved relatively high MED exceeding 120 mg/day. Conclusion Policy makers need to develop strategies for addressing high opioid use in WC systems.

Dixon K. Implementing mental health parity: The challenge for health plans. Health Affairs 28(3): 663-665, 2009. (0 refs.)

By design, the new mental health parity law should work harmoniously with innovations that have helped slow down growth in mental health and substance abuse (MH/SA) treatment costs and improve their quality. The main purpose of the new law is to put coverage of MH/SA benefits on an equal footing with general medical benefits. But some unique features of care for MH/SA disorders will pose challenges in aligning benefits with general medical care. Successful navigation of these challenges will require, as in the passage of the parity law itself, cooperation from all stakeholder groups.

Dorn SD; Meek PD; Shah ND. Increasing frequency of opioid prescriptions for chronic abdominal pain in US outpatient clinics. Clinical Gastroenterology and Hepatology 9(12): 1078-U179, 2011. (40 refs.)

BACKGROUND & AIMS: Opioids are sometimes used to treat chronic abdominal pain. However, opioid analgesics have not been proven to be an effective treatment for chronic abdominal pain and have been associated with drug misuse, constipation, and worsening abdominal pain. We sought to estimate the national prescribing trends and factors associated with opioid prescribing for chronic abdominal pain. METHODS: Chronic abdominal pain-related visits by adults to US outpatient clinics were identified using reason-for-visit codes from the National Ambulatory Medical Care Survey and National Hospital Ambulatory Medical Care Survey (1997-2008). Data were weighted to produce national estimates of opioid prescriptions over time. Logistic regression analyses, adjusted for complex survey design, were performed to identify factors associated with opioid use. RESULTS: The number of outpatient visits for chronic abdominal pain consistently decreased over time from 14.8 million visits (95% confidence interval [CI], 11.6-18.0 visits) in 1997 through 1999 to 12.2 million visits (95% CI, 9.0-15.6 visits) or 1863 visits per 100,000 population in 2006 through 2008 (P for trend = 0.04). Conversely, the adjusted prevalence of visits for which an opioid was prescribed increased from 5.9% (95% CI, 3.5%-8.3%) in 1997 through 1999 to 12.2% (95% CI, 7.5%-17.0%) in 2006 through 2008 (P = 0.03 for trend). Opioid prescriptions were most common among patients aged 25 to 40 years old (odds ratio [OR] 4.6; 95% CI, 1.2-18.4). Opioid prescriptions were less common among uninsured (OR 0.1; 95% CI, 0.04-0.40) and African American (OR 0.3; 95% CI, 0.1-0.9) patients. CONCLUSIONS: From 1997 to 2008 opioid prescriptions for chronic abdominal pain more than doubled. Further studies are needed to better understand the reasons for and consequences of this trend.

Downing SR; Oyetunji TA; Greene WR; Jenifer J; Rogers SO; Haider AH et al. The impact of insurance status on actuarial survival in hospitalized trauma patients: When do they die? Journal of Trauma, Injury, Infection and Critical Care 70(1): 130-135, 2011. (11 refs.)

Background: Previous work has suggested that insurance status, gender, and ethnicity all have an independent association with mortality after trauma. The purpose of this study is to investigate whether these factors exerted survival impact that could be observed throughout the hospital stay. Methods: Using the National Trauma Data Bank (version 7.0), a Cox proportional hazards survival analysis was performed on young (19-30 years old) trauma patients to mitigate the impact of comorbid confounders. Variables included in the model were age, gender, ethnicity, Injury Severity Score, presence of shock at presentation, mechanism of injury, insurance status, year of admission, teaching status of the hospital, diagnosis of substance abuse or psychotic disorders, and complications after admission. Rate ratios (RRs) comparing the slopes of the adjusted survival curves were calculated using the Mantel-Cox method. Results: A total of 192,488 young trauma patients were identified with complete data. Increased hazard of death was seen in patients who were uninsured (hazard ratio [HR] = 1.69, 95% confidence interval [CI] = 1.59-1.80, p < 0.001), of a minority ethnicity (HR = 1.08, 95% CI = 1.01-1.15, p = 0.025) or men (HR = 1.14, 95% CI = 1.04-1.23, p = 0.004). RRs were significantly larger between insurance status (RR = 1.75, 95% CI = 1.58-1.94, p < 0.001) than between race (RR = 1.23, 95% CI = 1.10-1.37, p < 0.001) or between gender (RR = 1.16, 95% CI = 1.01-1.32, p = 0.030). Conclusion: Risk of death on the first hospital day after injury differs by insurance status, and this disparity becomes more pronounced throughout the hospital stay. Further study is necessary to determine whether this is a result of additional unmeasured patient covariates with insurance status or a difference in provider behavior in response to patient insurance status.

Estee S; Wickizer T; He LJ; Shah MF; Mancuso D. Evaluation of the Washington State Screening, Brief Intervention, and Referral to Treatment project cost outcomes for medicaid patients screened in hospital emergency departments. Medical Care 48(1): 18-24, 2010. (47 refs.)

Background: Substance abuse is a major determinant of morbidity, mortality, and health care resource consumption. We evaluated a screening, brief intervention, and referral to treatment (SBIRT) program, implemented in 9 hospital emergency departments (ED) in Washington State. Methods: Working-age, disabled Medicaid patients who were screened and received a brief intervention (BI) from April 12, 2004 through September 30, 2006 were included in the study's intervention group (N = 1557). The comparison group (N = 1557), constructed using (one-to-one) propensity score matching, consisted of Medicaid patients who received care in one of the counties in which an intervention hospital ED was located but who did not receive a BI. We estimated difference-in-difference (DiD) regression models to assess the effects of the SBIRT program for different patient groups. Results: The SBIRT program was associated with an estimated reduction in Medicaid costs per member per month of $366 (P = 0.05) for all patients, including patients who received a referral for chemical dependency (CD) treatment. For patients who received a BI only and had no CD treatment in the year before or the year after the ED visit, the estimated reduction in Medicaid per member per month costs was $542 (P = 0.06). The SBIRT program was also associated with decreased inpatient utilization (P = 0.04). Conclusion: SBIRT programs have potential to limit resource consumption among working-age, disabled Medicaid patients. The hospital ED seems especially well suited for SBIRT programs given the large number of injured patients treated in the ED and the fact that many conditions treated are related to substance abuse.

Fussell HE; Rieckmann TR; Quick MB. Medicaid reimbursement for screening and brief intervention for substance misuse. Psychiatric Services 62(3): 306- 309, 2011. (7 refs.)

Objectives: Effective January 2008, state Medicaid plans may reimburse for screening and brief intervention for alcohol and drug misuse. This study assessed state Medicaid activity to implement Healthcare Common Procedure Code System codes and pay for screening and brief intervention. Methods: State and District of Columbia Medicaid representatives (N=44) participated in semistructured telephone interviews (N=37) or provided e-mail correspondence (N=7) about implementation of reimbursement codes. Confirmatory Web searches of Medicaid fee schedules supplemented findings and provided information for the remaining seven states. Results: More than half the states (N=28) list designated screening and brief intervention codes in their state Medicaid fee schedules; 19 of those states are capable of reimbursing for the codes. Qualitative analysis examined the challenges in choosing codes, assigning reimbursement rates, and working within constrained Medicaid budgets. Conclusions: Implementation of billing codes appears to be an insufficient policy mechanism to promote utilization of screening and brief intervention for treating substance use.

Garcia RA. Equity for all? Potential impact of the Mental Health Parity and Addiction Act of 2008. Journal of Legal Medicine 31(1): 137-155, 2010. (95 legal refs.)

An estimated 23 to 30 million adults are severely incapacitated from mental disorders, excluding those relating to substance abuse. Studies show that nearly 15% of the American population uses some type of mental health services in a given year. In spite of these astounding statistics, until recently mental health benefits in the United States lacked equal footing with their medical and surgical counterparts. Historically, many health care insurers have categorically excluded mental health benefits from coverage. If insurers covered mental health services at all, they were often subject to higher copayments per mental health visit, with limitations on the number of visits allowed. Additionally, many policies routinely contained "carve out" provisions, providing coverage for treatment by specific types of providers (such as social workers or psychologists) but imposing time limitations on treatment. Mental health parity legislation seeks to equalize the benefits provided by private insurers, requiring coverage for mental health services on a par with other medical conditions. Mental health parity advocates base their arguments primarily on the belief that health insurance providers should not discriminate against people with mental illness. As a result of the efforts of former Senators Pete Domenici and John Danforth, mental health parity legislation equalizing mental health benefits became law on October 3, 2008 as part of the Emergency Economic Stabilization Act of 2008. Section I of this commentary examines the history of mental health insurance coverage in the United States. Specifically, it provides an overview of the Mental Health Parity Act of 1996, including its limited scope and the difficulties that arose in its implementation. The section then provides an overview of the Mental Health Parity and Addiction Equity Act of 2008, which aimed to solve many of the problems that plagued the prior law. Section II presents common arguments for and against implementation of the 2008 Act, including those objections based upon economic considerations. Section III discusses possible resolutions to these arguments, including the advocacy of a new tier of mental health benefits coverage by health care providers. Finally, section IV concludes that, in practice, the 2008 Act will do little to ensure the equality of mental health benefits under the current health care landscape.

Garfield RL; Lave JR; Donohue JM. Health reform and the scope of benefits for mental health and substance use disorder services. Psychiatric Services 61(11): 1081-1086, 2010. (23 refs.)

The Patient Protection and Affordable Care Act will expand insurance coverage to millions of Americans with mental disorders. One particularly important implementation issue is the scope of mental health and substance abuse services under expanded health insurance coverage. This article examines current public and commercial insurance coverage of the range of services used by individuals with mental illnesses and substance use disorders and assesses the implications of newly mandated standards for benefit packages offered by public and private plans. The authors note that many services needed by individuals with mental or substance use disorders fall outside the scope of benefits currently covered by a typical private insurance plan. Compared with other insurers, Medicaid currently covers a broader range of behavioral health services; however, individuals moving into Medicaid under new eligibility pathways will receive "benchmark" or "benchmark-equivalent" coverage rather than full Medicaid benefits. If behavioral health benefits are set at those currently available in typical private plans or in benchmark coverage, some newly insured individuals with mental illnesses or substance use disorders who are covered by private plans or Medicaid expansions are still likely to face gaps in covered services. Policy makers have several options for addressing these likely gaps in coverage, including requiring states to maintain coverage of some support services, including certain behavioral health services in the "essential benefits package," and expanding eligibility for full Medicaid benefits.

Garner BR; Godley SH; Bair CML. The impact of pay-for-performance on therapists' intentions to deliver high-quality treatment. Journal of Substance Abuse Treatment 41(1): 97-103, 2011. (41 refs.)

This article examined the extent to which assignment to a pay-for-performance (P4P) experimental condition impacted therapists' intentions to deliver high-quality treatment and the extent to which therapists' intentions could be explained by the theory of planned behavior. Data were collected from 95 therapists who agreed to participate in a P4P experiment related to their implementation of an evidence-based treatment (EBT) for adolescents with substance use problems. Relative to those in the control condition, therapists in the P4P condition reported significantly greater intentions to achieve monthly competence (B = 1.41, p < .001) and deliver a targeted threshold level of treatment to clients (B = 1.31, p < .001). In addition, therapists' intentions could be partially explained by the theory of planned behavior. Meta-analyses have found intentions to be one of the best predictors of behavior; thus, these findings provide initial support for using P4P approaches as a method of increasing the quality of substance use treatment.

Harwood HJ; Zhang YD; Dall TM; Olaiya ST; Fagan NK. Economic implications of reduced binge drinking among the military health system's TRICARE prime plan beneficiaries. Military Medicine 174(7): 728-736, 2009. (33 refs.)

This study examines the economic burden of alcohol misuse to the Department of Defense (DoD) and the benefits of reduced binge drinking among beneficiaries in the DoD's TRICARE Prime plan. Data analyzed include administrative records for approximately 3 million beneficiaries age 18 to 64, DoD's Survey of Health Related Behaviors Among Military Personnel, and the National Survey on Drug Use and Health. Alcohol misuse among Prime beneficiaries cost the DoD an estimated $1.2 billion in 2006-$425 million in higher medical costs and $745 million in reduced readiness and misconduct charges. Potential annual gross benefits to the DoD of reduced binge drinking are simulated for three scenarios: (I) implementing a comprehensive alcohol screening with referral to brief intervention or treatment by primary care ($87 million/$129 million in short/long-term benefits); (2) increasing the price of alcoholic beverages on military installations by 20% ($75 million/$115 million); and (3) implementing a Web-based education program ($81 million/$123 million).

Higashi H; Khuong TA; Ngo AD; Hill PS. Population-level approaches to universal health coverage in resource-poor settings: Lessons from tobacco control policy in Vietnam. MEDICC Review 13(3): 39-42, 2011. (27 refs.)

Population-based health promotion and disease prevention approaches are essential elements in achieving universal health coverage; yet they frequently do not appear on national policy agendas. This paper suggests that resource-poor countries should take greater advantage of such approaches to reach all segments of the population to positively affect health outcomes and equity, especially considering the epidemic of chronic non-communicable diseases and associated modifiable risk factors. Tobacco control policy development and implementation in Vietnam provides a case study to discuss opportunities and challenges associated with such strategies.

Hodgkin D; Horgan CM; Garnick DW; Merrick EL. Benefit limits for behavioral health care in private health plans. Administration and Policy in Mental Health Services Research 36(1): 15-23, 2009. (36 refs.)

Data from a nationally representative sample of private health plans reveal that special lifetime limits on behavioral health care are rare (used by 16% of products). However, most plans have special annual limits on behavioral health utilization; for example, 90% limit outpatient mental health and 93% limit outpatient substance abuse treatment. As a result, enrollees in the average plan face substantial out-of-pocket costs for long-lasting treatment: a median of $2,710 for 50 mental health visits, or $2,400 for 50 substance abuse visits. Plans' access to new managed care tools has not led them to stop using benefit limits for cost containment purposes.

Hoffmann F; Hies M; Glaeske G. Regional variations of private prescriptions for the non-benzodiazepine hypnotics zolpidem and zopiclone in Germany. Pharmacoepidemiology and Drug Safety 19(10): 1071-1077, 2010. (28 refs.)

Purpose: Although evidence is lacking, there is general perception that zolpidem and zopiclone ('Z-drugs') are more effective and safer than benzodiazepines leading to an increased prescribing of Z-drugs. In Germany, 85% of the inhabitants are covered by statutory health insurance (SHI), the rest is privately insured. Z-drugs are covered by SHIs but physicians can also provide private prescriptions for SHI insured persons, who then have to pay for these out of pocket. Since private prescriptions are not documented in SHI claims data, physicians might prescribe drugs associated with abuse as private prescriptions. We aim to quantify SHE versus private prescriptions of Z-drugs and analyze regional variations. Methods We studied a sample of 2500 community pharmacies located across Germany from 2006 to 2008. We analyzed the amount of private prescriptions in numbers of packages. Drug utilization was expressed in defined daily doses (DDDs) per 1000 inhabitants per day (DID). Results: The proportions of private prescriptions ranged between 36.7% and 36.9% per annum for zopiclone, this was significantly higher for zolpidem (49.4-49.6% per annum). There are substantial regional variations for zolpidem (28.8-82.6%) and zopiclone (22.5-68.6%). In all federal states the proportion of zolpidem not reimbursed by SHIs is higher than that of zopiclone (6.3-15.4%). The nation-wide outpatient consumption was 2.5 DID for zolpidem and 2.7 DID for zopiclone with large regional variations. Conclusions In addition to large regional variations, zolpidem is more often prescribed as a private prescription than zopiclone. This might be a signal for a higher abuse potential of zolpidem.

Holtrop JS; Meghea C; Raffo JE; Biery L; Chartkoff SB; Roman L. Smoking among pregnant women with Medicaid insurance: Are mental health factors related? Maternal and Child Health Journal 14(6): 971-977, 2010. (33 refs.)

Smoking during pregnancy is the single most modifiable risk factor for poor birth outcomes, yet it remains prevalent among low-income women. This study examined factors associated with continued smoking and quitting among pregnant women. A total of 2,203 Medicaid-eligible pregnant women were screened at their first enhanced prenatal services visit for risk factors including demographics, health behaviors (smoking, alcohol and drug use), mental health (history of mental health disorders, current depressive symptoms), and stress. Smoking status was divided into non-smokers, quitters (quit smoking since learning of pregnancy), and continuing smokers. Descriptive statistics and logistic regression models were used to describe the sample and analyze relationships between smoking status and other characteristics. Overall, 57% were non-smokers, 17% quitters, and 26% continuing smokers. Approximately 18% had severe depressive symptoms, 53% had a high stress score, and 33% had a history of mental health problems. Younger women had lower odds of continued smoking as compared to both non-smokers (OR = 0.48, p < 0.01) and quitters (OR = 0.56, p < 0.05). Older women with less than a 12th grade education had higher odds of continued smoking (OR = 2.17, p < 0.01) and quitting (OR = 1.62, p < 0.05) as compared to non-smokers. Alcohol use (OR = 2.81, p < 0.05) and drug use before pregnancy (OR = 5.32, p < 0.01) predicted continued smoking compared to non-smoking. Women with a mental health history (OR = 1.81, p < 0.01) and high stress scores (OR = 1.39, p < 0.05) had higher odds of continued smoking compared to non-smokers. Mental health history, stress, demographics, current alcohol and past drug use are strongly related to continued smoking in this population.

Horgan CM; Garnick DW; Merrick EL; Hodgkin D. Changes in how health plans provide behavioral health services. Journal of Behavioral Health Services and Research 36(1): 11-24, 2009. (29 refs.)

Health plans appear to be moving toward less stringent management, but it is not known whether behavioral health care arrangements mirror the overall trend. To improve access to and quality of behavioral health services, it is critical to track plans' delivery of these services. This study examined plans' behavioral health care arrangements and changes over time using a nationally representative health plan survey regarding alcohol, drug abuse, and mental health services in 1999 (N = 434, 92% response) and 2003 (N = 368, 83% response). Findings indicate health plans' behavioral health service provision changed significantly since 1999, including a large increase in contracting with managed behavioral health care organizations. Some evidence of loosening administrative controls such as prior authorization implies easier access to services. However, increased prevalence of higher levels of cost sharing suggests financial barriers have grown. These changes have important implications for enrollees seeking care and for providers working to meet patients' needs.

Hughes JR. How confident should we be that smoking cessation treatments work? (review). Addiction 104(10): 1637-1640, 2009. (44 refs.)

Aim: To determine (i) the concordance among recent meta-analyses about which treatments for smoking cessation are efficacious; (ii) the similarity of odds ratios (ORs) across meta-analyses; and (iii) among the validated treatments, the proportion of studies that found higher quit rates. Methods: Computerized literature search for meta-analyses during the last 5 years in PubMed and PsychInfo. Data were extracted from summary tables of overall effect of validated treatments. Results: Fourteen meta-analyses agreed 100% on the presence/absence of efficacy of 17 proven treatments. The ORs differed by < 0.5 in 72/76 of the comparisons of meta-analyses. Among 37 comparisons in 33 comparisons, > 85% of the studies reported numerical superiority for the active treatment. Conclusions: The efficacy of treatments for smoking cessation are extremely reliable. This argues for inclusion of treatment as an essential feature of tobacco control and clinical practice and argues for reimbursement of smoking cessation treatments on a par with other medical and behavioral disorders.

Ireys HT; Barrett AL; Buck JA; Croghan TW; Au M; Teich JL. Medicaid beneficiaries using mental health or substance abuse services in fee-for-service plans in 13 States, 2003. Psychiatric Services 61(9): 871-877, 2010. (15 refs.)

Objective: This study identified Medicaid beneficiaries using mental health or substance abuse services in fee-for-service plans in 13 states in 2003 (N=1,380,190) and examined their use of medical services. Methods: Administrative and fee-for-service claims data from Medicaid Analytic eXtract files were analyzed to identify mutually exclusive groups of beneficiaries who used either mental health or substance abuse services and to describe patterns of medical service use. Results: Overall, 11.7% of Medicaid beneficiaries were identified as using mental health or substance abuse services (10.9% and.7% used each of these services, respectively), with substantial variation across age and eligibility groups. Among beneficiaries using mental health services, 47.4% had visited an emergency room for any reason, 7.8% were treated for their disorder in inpatient settings, 13.8% received inpatient treatment for problems other than their mental or substance use disorders, and 70.4% received prescriptions for psychotropic medications. Among beneficiaries using substance abuse services, 60.7% had visited an emergency room, 12.6% were treated for their disorder in inpatient settings, 24.7% received other inpatient treatment, and 46.1% received prescriptions for psychotropic medications. Among beneficiaries not using either mental health or substance use services, 29.0% had visited an emergency room, 12.7% received inpatient treatment, and 10.1% received prescriptions for psychotropic medications. Conclusions: Beneficiaries who used mental health or substance abuse services entered general inpatient settings and visited emergency rooms more frequently than other beneficiaries.

Keller PA; Christiansen B; Kim SY; Piper ME; Redmond L; Adsit R et al. Increasing consumer demand among medicaid enrollees for tobacco dependence treatment: The Wisconsin "Medicaid Covers It" Campaign. American Journal of Health Promotion 25(6): 392-395, 2011. (10 refs.)

Purpose. Smoking prevalence among Medicaid enrollees is higher than among the general population, but use of evidence-based cessation treatment is low. We evaluated whether a communications campaign improved cessation, treatment utilization. Design. Quasi-experimental. Setting. Wisconsin. Subjects. Enrollees in the Wisconsin Family Medicineicaid program. The average monthly enrollment during the study period was approximately 1 70,000 individuals. Intervention. Print materials fir clinicians and consumers distributed to 13 health maintenance organizations (HMOs) serving Wisconsin Medicaid HMO enrollees. Measures. Wisconsin Medicaid pharmacy claims data for smoking cessation medications were analyzed before and after a targeted communications campaign. HMO enrollees were the intervention group. Fee-for-service enrollees were a quasi-experimental comparison group. Quit Line utilization data were also analyzed. Analysis. Pharmacotherapy claims and number of registered Quit Line callers were compared precampaign and postcampaign. Results. Precampaign, cessation pharmacotherapy claims declined for the intervention group and increased slightly for the comparison, group (t = 2.20, p = .03). Postcampaign, claims increased in both groups. However, the rate of increase in the intervention group was significantly greater than in the comparison group (t = -2.2, p = .04). A statistically significant increase was also seen in the average monthly number of Medicaid enrollees that registered for Quit Line services postcampaign compared to precampaign (F [1,22] = 7.19, p = .01). Conclusion. This natural experiment demonstrated statistically significant improvements in both pharmacotherapy claims and Quit Line registrations among Medicaid enrollees. These findings may help inform other states' efforts to improve cessation treatment utilization.

Kennedy J; Dipzinski A; Roll J; Coyne J; Blodgett E. Medicare prescription drug plan coverage of pharmacotherapies for opioid and alcohol dependence in WA. Drug and Alcohol Dependence 114(2-3): 201- 206, 2011. (43 refs.)

Objectives: Pharmacotherapeutic treatments for drug addiction offer new options, but only if they are affordable for patients. The objective of this study is to assess the current availability and cost of five common antiaddiction medications in the largest federal medication insurance program in the US, Medicare Part D. Methods: In early 2010, we collected coverage and cost data from 41 Medicare Part D prescription drug plans (PDPs) and 45 Medicare Advantage Plans (MAPs) in Washington State. Results: The great majority of Medicare plans (82-100%) covered common pharmacotherapeutic treatments for drug addiction. These Medicare plans typically placed patent protected medications on their highest formulary tiers, leading to relatively high patient co-payments during the initial Part D coverage period. For example, median monthly co-payments for buprenorphine (Suboxone (R)) were about $46 for PDPs, and about $56 for MAPs. Conclusion: While Medicare prescription plans usually cover pharmacotherapeutic treatments for drug addiction, high co-payments can limit access. For example, beneficiaries without supplemental coverage who use Vivitrol (R) would exceed their initial coverage cap in 7-8 months, reaching the "doughnut hole" in their Part D coverage and becoming responsible for the full cost of the medication (over $900 per month). The 2010 Patient Protection and Affordable Care Act will gradually eliminate this coverage gap, and loss of patent protection for other antiaddiction medications (Suboxone and Campral (R)) should also drive down patient costs, improving access and compliance.

Kilbourne BJ; Cummings SM; Levine R. Alcohol diagnoses among older Tennessee Medicare beneficiaries: Race and gender differences. International Journal of Geriatric Psychiatry 27(5): 483-490, 2012. (45 refs.)

Background: These analyses bolster a sparse body of research focusing on the rate of alcohol disorders among older adults, particularly race and gender subgroups. Methods: We based the study on cross-sectional data from all Medicare billed physician/patient encounters. Analyses of these data included cross-tabulations, difference of means tests, and difference of proportions tests, logistic regression and multinomial logistic regression. These analyses were based Medicare billing records from physician/patient encounters in Tennessee. Data included Tennessee Medicare billings beneficiaries enrolled in Medicare Part B, who saw a physician at least once in 2000. Patients with billings containing ICD-9 codes: 303 (alcohol abuse), 305 (alcohol dependence), 291 (alcohol psychosis), or 571.1-571.3 (alcohol-related liver disease including cirrhosis of the liver) as to primary diagnosis were considered alcohol-disordered. Results: Analyses reveal the overall rate of alcohol disorders, subgroup variation in rates and differences in pattern of specific disorders. Merely 0.04% of Tennessee Medicare beneficiaries were diagnosed with any type of alcoholism, a rate much lower than those reported in previous studies. Rates of alcohol disorders varied across groups, with significantly higher rates for Black men. The type alcohol disorder also varied across groups. Conclusions: Many encounters with the medical system result in missed opportunities to identify and treat alcohol disorders, a significant risk factor among older adults. Alcoholism both triggers and exacerbates many chronic conditions among older adults. The earlier in the disease trajectory the more of these conditions could be prevented or more efficiently managed, resulting in substantial savings in health care costs.

King B; Kaplan S; Hofstedt T. A field experiment in capitated payment systems and recovery management: The women's recovery association pilot study. Journal of Psychoactive Drugs Supplement 6: 287-293, 2010. (9 refs.)

Against the backdrop of shifting perspectives regarding substance abuse policy, upcoming changes to the health care system, and progress toward parity for mental health and substance abuse treatment, an exploratory pilot study is being conducted in San Mateo County, California, to assess the potential of a capitated case rate combined with a recovery management approach in a community-based substance abuse treatment program for women. The rationale for developing the approach, planning, and implementation of the pilot project, the struggle of the agency to transform from episodic treatment to a chronic care model, and a case study that highlights organizational changes are discussed. Lessons learned and implications for the second year of the pilot project are also discussed.

Kranzler HR; Montejano LB; Stephenson JJ; Wang SH; Gastfriend DR. Effects of naltrexone treatment for alcohol-related disorders on healthcare costs in an insured population. Alcoholism: Clinical and Experimental Research 34(6): 1090-1097, 2010. (27 refs.)

Objective: To determine the impact of treatment with oral naltrexone on healthcare costs in patients with alcohol-related disorders. Methods: Using data from the MarketScan Commercial Claims and Encounters Database for 2000-2004, we identified a naltrexone group (with an alcohol-related diagnosis and at least one pharmacy claim for oral naltrexone) and two control groups. Alcohol controls had an alcohol-related diagnosis and were not prescribed an alcoholism treatment medication. Nonalcohol controls had no alcohol-related diagnosis and no prescription for an alcoholism treatment medication. The control groups were matched three to one to the naltrexone group on demographic and other relevant measures. Healthcare expenditures were calculated for the 6-month periods before and after the index naltrexone drug claim (or matched date for controls). Univariate and multivariate analyses were used to compare the groups on key characteristics and on healthcare costs. Results: Naltrexone patients (n = 1,138; 62% men; mean age 45 +/- 11 years) had significantly higher total healthcare expenditures in the pre-index period than either of the control groups. In the postindex period, naltrexone patients had a significantly smaller increase than alcohol controls in total alcohol-related expenditures. Total nonalcohol-related expenditures also increased significantly less for the naltrexone group than for the alcohol control group. Multivariate analyses showed that naltrexone treatment significantly reduced alcohol-related, nonalcohol-related, and total healthcare costs relative to alcohol controls. Conclusions: Although prior to treatment patients with alcohol-related disorders had higher healthcare costs, treatment with oral naltrexone was associated with reductions both in alcohol-related and nonalcohol-related healthcare costs.

Land T; Rigotti NA; Levy DE; Paskowsky M; Warner D; Kwass JA et al. A longitudinal study of Medicaid coverage for tobacco dependence treatments in Massachusetts and associated decreases in hospitalizations for cardiovascular disease. PLoS Medicine 7(12): e1000375, 2010. (25 refs.)

Background: Insurance coverage of tobacco cessation medications increases their use and reduces smoking prevalence in a population. However, uncertainty about the impact of this coverage on health care utilization and costs is a barrier to the broader adoption of this policy, especially by publicly funded state Medicaid insurance programs. Whether a publicly funded tobacco cessation benefit leads to decreased medical claims for tobacco-related diseases has not been studied. We examined the experience of Massachusetts, whose Medicaid program adopted comprehensive coverage of tobacco cessation medications in July 2006. Over 75,000 Medicaid subscribers used the benefit in the first 2.5 years. On the basis of earlier secondary survey work, it was estimated that smoking prevalence declined among subscribers by 10% during this period. Methods and Findings: Using claims data, we compared the probability of hospitalization prior to use of the tobacco cessation pharmacotherapy benefit with the probability of hospitalization after benefit use among Massachusetts Medicaid beneficiaries, adjusting for demographics, comorbidities, seasonality, influenza cases, and the implementation of the statewide smoke-free air law using generalized estimating equations. Statistically significant annualized declines of 46% (95% confidence interval 2%-70%) and 49% (95% confidence interval 6%-72%) were observed in hospital admissions for acute myocardial infarction and other acute coronary heart disease diagnoses, respectively. There were no significant decreases in hospitalizations rates for respiratory diagnoses or seven other diagnostic groups evaluated. Conclusions: Among Massachusetts Medicaid subscribers, use of a comprehensive tobacco cessation pharmacotherapy benefit was associated with a significant decrease in claims for hospitalizations for acute myocardial infarction and acute coronary heart disease, but no significant change in hospital claims for other diagnoses. For low-income smokers, removing the barriers to the use of smoking cessation pharmacotherapy has the potential to decrease short-term utilization of hospital services.

Land T; Warner D; Paskowsky M; Cammaerts A; Wetherell L; Kaufmann R et al. Medicaid coverage for tobacco dependence treatments in Massachusetts and associated decreases in smoking prevalence. PLoS Oone 5(3): e9770, 2010. (12 refs.)

Background: Approximately 50% of smokers die prematurely from tobacco-related diseases. In July 2006, the Massachusetts health care reform law mandated tobacco cessation coverage for the Massachusetts Medicaid population. The new benefit included behavioral counseling and all medications approved for tobacco cessation treatment by the U. S. Food and Drug Administration (FDA). Between July 1, 2006 and December 31, 2008, a total of 70,140 unique Massachusetts Medicaid subscribers used the newly available benefit, which is approximately 37% of all Massachusetts Medicaid smokers. Given the high utilization rate, the objective of this study is to determine if smoking prevalence decreased significantly after the initiation of tobacco cessation coverage. Methods: and Findings: Smoking prevalence was evaluated pre- to post-benefit using 1999 through 2008 data from the Massachusetts Behavioral Risk Factor Survey (BRFSS). The crude smoking rate decreased from 38.3% (95% C. I. 33.6%-42.9%) in the pre-benefit period compared to 28.3% (95% C. I.: 24.0%-32.7%) in the post-benefit period, representing a decline of 26 percent. A demographically adjusted smoking rate showed a similar decrease in the post-benefit period. Trend analyses reflected prevalence decreases that accrued over time. Specifically, a joinpoint analysis of smoking prevalence among Massachusetts Medicaid benefit-eligible members (age 18-64) from 1999 through 2008 found a decreasing trend that was coincident with the implementation of the benefit. Finally, a logistic regression that controlled for demographic factors also showed that the trend in smoking decreased significantly from July 1, 2006 to December 31, 2008. Conclusion: These findings suggest that a tobacco cessation benefit that includes coverage for medications and behavioral treatments, has few barriers to access, and involves broad promotion can significantly reduce smoking prevalence.

Levy DE; Rigotti NA; Winickoff JP. Medicaid expenditures for children living with smokers. BMC Health Services Research 11(e-article 125), 2011. (30 refs.)

Background: Children's exposure to secondhand smoke is associated with increased morbidity. We estimated Medicaid expenditures for children living with smokers compared to those living with no smokers in the United States. Methods: Data were overall and service-specific (i.e., inpatient, ambulatory, emergency department, prescription drug, and dental) annual Medicaid expenditures for children 0-11 years old from the 2000-2007 Medical Expenditures Panel Surveys. Smokers' presence in households was determined by adult respondents' self reports. There were 25,835 person-years of observation. We used multivariate analyses to adjust for child, parent, and geographic characteristics. Results: Children with Medicaid expenditures were nearly twice as likely to live with a smoker as other children in the U.S. population. Adjusted analyses revealed no detectable differences in children's overall Medicaid expenditures by presence of smokers in the household. Medicaid children who lived with smokers on average had $10 (95% CI $3, $18) higher emergency department expenditures per year than those living with no smokers. Conclusions: Living with at least one smoker (a proxy for secondhand smoke exposure) is unrelated to children's overall short-term Medicaid expenditures, but has a modest impact on emergency department expenditures. Additional research is necessary to understand the relationship between secondhand smoke exposure and long-term health and economic outcomes.

Liddy C; Singh J; Hogg W; Dahrouge S; Taljaard M. Comparison of primary care models in the prevention of cardiovascular disease: A cross sectional study. BMC Family Practice 12: 114, 2011. (36 refs.)

Background: Primary care providers play an important role in preventing and managing cardiovascular disease. This study compared the quality of preventive cardiovascular care delivery amongst different primary care models. Methods: This is a secondary analysis of a larger randomized control trial, known as the Improved Delivery of Cardiovascular Care (IDOCC) through Outreach Facilitation. Using baseline data collected through IDOCC, we conducted a cross-sectional study of 82 primary care practices from three delivery models in Eastern Ontario, Canada: 43 fee-for-service, 27 blended-capitation and 12 community health centres with salary-based physicians. Medical chart audits from 4,808 patients with or at high risk of developing cardiovascular disease were used to examine each practice's adherence to ten evidence-based processes of care for diabetes, chronic kidney disease, dyslipidemia, hypertension, weight management, and smoking cessation care. Generalized estimating equation models adjusting for age, sex, rurality, number of cardiovascular-related comorbidities, and year of data collection were used to compare guideline adherence amongst the three models. Results: The percentage of patients with diabetes that received two hemoglobin A1c tests during the study year was significantly higher in community health centres (69%) than in fee-for-service (45%) practices (Adjusted Odds Ratio (AOR) = 2.4 [95% CI 1.4-4.2], p = 0.001). Blended capitation practices had a significantly higher percentage of patients who had their waistlines monitored than in fee-for-service practices (19% vs. 5%, AOR = 3.7 [1.8-7.8], p = 0.0006), and who were recommended a smoking cessation drug when compared to community health centres (33% vs. 16%, AOR = 2.4 [1.3-4.6], p = 0.007). Overall, quality of diabetes care was higher in community health centres, while smoking cessation care and weight management was higher in the blended-capitation models. Fee-for-service practices had the greatest gaps in care, most noticeably in diabetes care and weight management. Conclusions: This study adds to the evidence suggesting that primary care delivery model impacts quality of care. These findings support current Ontario reforms to move away from the traditional fee-for-service practice.

Lillie-Blanton M; Stone VE; Jones AS; Levi J; Golub ET; Cohen MH et al. Association of race, substance abuse, and health insurance coverage with use of highly active antiretroviral therapy among HIV-Infected women, 200518. American Journal of Public Health 100(8): 1493-1499, 2010. (18 refs.)

Objectives. We examined racial/ethnic disparities in highly active antiretroviral therapy (HAART) use and whether differences are moderated by substance use or insurance status, using data from the Women's Interagency HIV Study (WIHS). Methods. Logistic regression examined HAART use in a longitudinal cohort of women for whom HAART was clinically indicated in 2005 (N=1354). Results. Approximately 3 of every 10 eligible women reported not taking HAART. African American and Hispanic women were less likely than were White women to use HAART. After we adjusted for potential confounders, the higher likelihood of not using HAART persisted for African American but not for Hispanic women. Uninsured and privately insured women, regardless of race/ethnicity, were less likely than were Medicaid enrollees to use HAART. Although alcohol use was related to HAART nonuse, illicit drug use was not. Conclusions. These findings suggest that expanding and improving insurance coverage should increase access to antiretroviral therapy across racial/ethnic groups, but it is not likely to eliminate the disparity in use of HAART between African American and White women with HIV/AIDS.

Lin WC; Zhang JY; Leung GY; Clark RE. Twelve-month diagnosed prevalence of behavioral health disorders among elderly Medicare and Medicaid members. American Journal of Geriatric Psychiatry 19(11): 970-979, 2011. (37 refs.)

Objectives: We examined the 12-month diagnosed prevalence of behavioral health disorders (BHDs) and dementia among elderly Medicare and Medicaid members in Massachusetts by primary payment source group (dual eligible, Medicare only, and Medicaid only) and age group (65-74 years, 75-84 years, and 85 years and older). Design: A retrospective cross-sectional study. Setting: Medicare and Medicaid programs. Participants: Massachusetts Medicare or Medicaid enrollees age 65 and older as of January 1, 2005, (N = 679,182). Measurements: International Classification of Diseases, Ninth Revision, Clinical Modification diagnosis codes recorded on Medicare and Medicaid claims were used to identify the BHDs. Results: The 12-month diagnosed prevalence was 19.4% for any BHD and 11.2% for dementia. The most common BHDs by disease category were major depression (severe mental illness [SMI]), other depression (other mental illness [OMI]), and alcohol abuse or dependence (subtance use disorder [SUD]). Dual eligibles had a considerably higher diagnosed prevalence of any BHD (38.8%), compared with 16.1% in the Medicare only group. The 12-month diagnosed prevalence of SMI, OMI, and dementia was higher in the older-age groups. Co-occurring SUD was higher for younger dual eligibiles. Dementia and mental illness co-occurred at much higher rates for dual eligibles than for either of the single-insurance groups. This combination increased with age in all three groups. Conclusions: The 12-month prevalence of BHDs and dementia among elderly dual eligibles was disproportionately higher than other elderly Medicare or Medicaid members. However, access barriers to behavioral health services for this vulnerable population could be significant because Medicare and Medicaid payment limitations resulted in financial disincentives for providing these services.

Liu F. Effect of Medicaid coverage of tobacco-dependence treatments on smoking cessation. International Journal of Environmental Research and Public Health 6(12): 3143-3155, 2009. (34 refs.)

Smoking cessation aids (nicotine replacement products and anti-depressant medication) have been proven to double quitting rates compared to placebo in several randomized controlled trials. But the high initial cost of cessation aids might create a financial barrier to cessation for low-income smokers. In the U.S., Medicaid provides health insurance coverage to low-income people, and in some states covers smoking cessation products. This paper uses nationally representative data of the U. S. to examine how the Medicaid coverage of cessation aids affect smoking behavior. The results indicate the Medicaid coverage of cessation products is positively associated with successful quitting among women aged 18-44.

Liu F. Quit attempts and intention to quit cigarette smoking among Medicaid recipients in the USA. Public Health 124(10): 553-558, 2010. (30 refs.)

Objectives: To examine the effect of Medicaid coverage of tobacco dependence treatments (TDT) on quitting attempts and intention to quit by Medicaid recipient smokers. Study design: Multiple cross-sectional study. Method: Data from the national 1996-2007 Tobacco Use Supplements to the Current Population Survey in the USA were analysed (n = 6585). Measures included self-reported quit attempts during the last 12 months, and serious intention to quit in the next 6 months and in the next 30 days. Results: In the baseline model, Medicaid coverage of TDT was associated with attempted quitting [odds ratio (OR) 1.23, 95% confidence interval (CI) 1.05-1.45], intention to quit in the next 6 months (OR 1.32, 95% CI 1.09-1.59) and intention to quit in the next 30 days (OR 1.27, 95% CI 1.01-1.58). After controlling for cigarette taxes and the antismoking sentiment index for each state, the magnitude became smaller and the association was only statistically significant for intention to quit in the next 6 months. Conclusions: Covering smoking cessation aids and eliminating copayments with Medicaid can encourage more quitting attempts and facilitate intentions to quit.

Lowe RA; Fu RW; Gallia CA. Impact of policy changes on emergency department use by medicaid enrollees in Oregon. Medical Care 48(7): 619-627, 2010. (30 refs.)

Objective: In 2003, Oregon's Medicaid expansion program, the Oregon Health Plan (OHP), implemented premiums and copayments and eliminated outpatient behavioral health services. We ascertained whether these changes, including $50 copayments for emergency department (ED) visits, affected ED use. Methods: This study used statewide administrative data on 414,009 adult OHP enrollees to compare ED utilization rates (adjusted for patient characteristics) in 3 time periods: (1) before the cutbacks, (2) after the cutbacks, and (3) after partial restoration of benefits. We examined overall ED visits and several subsets of ED visits: visits requiring hospital admission, injury-related, drug-related, alcohol-related, and other psychiatric visits. Because the policy changes affected only the expansion program (OHP Standard), we ascertained the impact of these changes compared with a control group of categorically eligible Medicaid enrollees (OHP Plus). Results: Compared with the control group, case-mix-adjusted ED utilization rates fell 18% among OHP Standard enrollees after the cutbacks. The rate of ED visits leading to hospitalization fell 24%. Injury-related visits and psychiatric visits excluding chemical dependency exhibited a similar pattern to overall ED visits. Drug-related ED visits increased 32% in the control group, perhaps reflecting the closure of drug treatment programs after the cutbacks reduced their revenue. Conclusion: The policy changes were followed by a substantial reduction in ED use. That ED visits requiring hospital admission fell to about the same extent as overall ED use suggests that OHP enrollees may have been discouraged from using EDs for emergencies as well as less-serious problems.

Mark TL; Vandivort-Warren R; Miller K. Mental health spending by private insurance: Implications for the Mental Health Parity and Addiction Equity Act. Psychiatric Services 63(4): 313-318, 2012. (12 refs.)

Objective: The study developed information on behavioral health spending and utilization that can be used to anticipate, evaluate, and interpret changes in health care spending following implementation of the Mental Health Parity and Addiction Equity Act (MHPAEA). Methods: Data were from the Thomson Reuters' Market Scan database of insurance claims between 2001 and 2009 from large group health plans sponsored by self-insured employers. Annual rates in growth of total health spending and behavioral health spending and the contribution of behavioral health spending; to growth in spending for all diseases were determined. Separate analyses examined behavioral health and total health spending by 135 employers in 2008 and 2009, and simulations were conducted to determine how increases in use of mental health services after implementation of parity would affect overall health care expenditures. Results: Across the nine years examined, behavioral health expenditures contributed .3%, on average, to the total rate of growth in all health expenditures, a contribution that fell to .1%, on average, when prescription drugs were excluded. About 2% of employers experienced an increased contribution by behavioral health spending of more than 1%. More than 90% of enrollees used well below the maximum 30 inpatient days or outpatient visits typical of health insurance plans before parity. Simulations indicated that even large increases in utilization would increase total health care expenditures by less than 1%. Conclusions: The MHPAEA is unlikely to have a large effect on the growth rate of employers' health care expenditures. The data provide baseline information to further evaluate the implementation effect of the MHPAEA.

Mauldin JA. All smoke and no fire? Analyzing the potential effects of the Mental Health Parity and Addiction Equity Act of 2008. Law & Psychology Review 35: 193, 2011. (122 legal refs.)

... The way in which mental health services have been and continue to be regulated in this country cannot be understood without a general understanding of the larger historical context of mental health treatment. ... Specifically, the bill would have required services considered essential to the treatment of severe mental illness to be provided in a manner that "(1) was not more restrictive than coverage provided for other major physical illnesses; (2) provided adequate financial protection to the person requiring the medical treatment . . . ; and (3) was consistent with effective and common methods of controlling health care costs for other major physical illnesses." ... The GAO further found, the net effect is that consumers in states without more comprehensive laws have often seen only minor changes in their health benefits, resulting in little or no increase in their access to mental health services, and that the costs associated with the federal law have been negligible for most health plans. ... The provision reduced the incentive for insurance companies and benefit providers to make long-term shifts toward mental health parity in hopes of nonrenewal. ... What It Does In rising to support the MHPAEA, Representative Pallone stated, "the legislation before us will fully ensure equity in the coverage for mental illness and substance abuse disorders by requiring that group health plans with mental health coverage offer that coverage without the imposition of discriminatory financial requirements or discriminatory treatment limitations." ... The PPACA attempts to broaden access to care by requiring most citizens to purchase health insurance, creating state-based insurance exchanges where some individuals will be eligible for premium and cost-sharing benefits, penalizing employers whose employees obtain coverage through the exchanges, and extending Medicaid eligibility.

McAdam-Marx C; McGarry LJ; Hane CA; Biskupiak J; Deniz B; Brixner DI. All-cause and incremental per patient per year cost associated with chronic hepatitis C virus and associated liver complications in the United States: A managed care perspective. Journal of Managed Care Pharmacy 17(7): 531-546, 2011. (44 refs.)

BACKGROUND: Approximately 3.2-3.9 million U.S. residents are infected with the hepatitis C virus (HCV). Total annual costs (direct and indirect) in the United States for HCV were estimated to be $5.46 billion in 1997, and direct medical costs have been predicted to increase to $10.7 billion for the 10-year period from 2010 through 2019, due in part to the increasing number of HCV patients developing advanced liver disease (AdvLD). OBJECTIVE: To quantify in a sample of commercially insured enrollees (a) total per patient per year (PPPY) all-cause costs to the payer, overall and by the stage of liver disease, for patients diagnosed with HCV; and (b) incremental all-cause costs for patients diagnosed with HCV relative to a matched non-HCV cohort. METHODS: This retrospective, matched cohort study included patients aged at least 18 years and with at least 6 months of continuous enrollment in a large managed care organization (MCO) claims database from July 1, 2001, through March 31, 2010. Patients with a diagnosis of HCV (ICD-9-CM codes 070.54, 070.70) were identified and stratified into those with and without AdvLD, defined as decompensated cirrhosis (ICD-9-CM codes 070.44, 070.71, 348.3x, 456.0, 456.1, 456.2x, 572.2, 572.3, 572.4, 782.4, 789.59); hepatocellular carcinoma (HCC, ICD-9-CM code 155); or liver transplant (ICD-9-CM codes V42.7, 50.5 or CPT codes 47135, 47136). For patients without AdvLD, the index date was the first HCV diagnosis date observed at least 6 months after the first enrollment date, and at least 6 months of continuous enrollment after the index date were required. HCV patients without AdvLD were stratified into those with and without compensated cirrhosis (ICD-9-CM codes 571.2, 571.5, 571.6). For patients with AdvLD, the index date was the date of the first AdvLD diagnosis observed at least 6 months after the first enrollment date, and at least 1 day of enrollment after the index date was required. Cases were matched in an approximate 1:10 ratio to comparison patients without an HCV diagnosis or AdvLD diagnosis who met all other inclusion criteria based on gender, age, hospital referral region state, pre-index health care costs, alcoholism, human immunodeficiency virus/acquired immune deficiency syndrome (HIV/AIDS), and a modified Charlson Comorbidity Index. For the HCV and comparison patient cohorts, PPPY all-cause costs to the payer were calculated as total allowed charges summed across all patients divided by total patient-days of follow-up for the cohort, multiplied by 365, inflation-normalized to 2009 dollars. Because the calculation of PPPY cost generated a single value for each cohort, bootstrapping was used to generate descriptive statistics. Incremental PPPY costs for HCV patients relative to non-HCV patients were calculated as between-group differences in PPPY costs. T-tests for independent samples were used to compare costs between case and comparison cohorts. RESULTS: A total of 34,597 patients diagnosed with HCV, 78.0% with HCV without AdvLD, 4.4% with compensated cirrhosis, 12.3% with decompensated cirrhosis, 2.8% with HCC, and 2.6% with liver transplant, were matched to 330,435 comparison patients. Mean (SD) age of all HCV cases was 49.9 (8.5) years; 61.7% were male. Incremental mean (SD) PPPY costs in 2009 dollars for all HCV patients relative to comparison patients were $9,681 ($176) PPPY. Incremental PPPY costs were $5,870 ($157) and $5,330 ($491) for HCV patients without liver disease and with compensated cirrhosis, respectively. Incremental PPPY costs for patients with AdvLD were $27,845 ($965) for decompensated cirrhosis, $43,671 ($2,588) for HCC, and $93,609 ($4,482) for transplant. Incremental prescription drug costs, including the cost of antiviral drugs, were $2,739 ($37) for HCV patients overall, $2,659 ($41) for HCV without liver involvement, and $3,102 ($157) for HCV with compensated cirrhosis. These between-group differences were statistically significant at P<0.001. CONCLUSIONS: Based on a retrospective analysis of data from a large, MCO claims database, patients diagnosed with HCV had annual all-cause medical costs that were almost twice as high as those of enrollees without a diagnosis of HCV. Health care costs increased dramatically with AdvLD. Data from this study may help MCOs project future HCV costs and facilitate planning for HCV patient management efforts. [Note. HCV is associated with injecting drug use.]

McBride DC; Chriqui JF; Terry-McElrath YM; Mulatu MS. Drug treatment program ownership, Medicaid acceptance, and service provision. Journal of Substance Abuse Treatment 42(2, special issue): 116, 2012. (45 refs.)

The Institute of Medicine noted that effective substance abuse treatment (SAT) programs integrate individual therapeutic approaches with transitional/ancillary services. In addition, research suggests that type of ownership impacts SAT services offered and that Medicaid plays a key role in SAT access. Data from the National Survey of Substance Abuse Treatment Services for the years 2000 and 2002-2006 were used to examine relationships among SAT program Medicaid acceptance, program ownership, and transitional/ancillary service accessibility. Multivariate logistic regression models controlling for state- and program-level contextual factors were used to analyze the data. Nonprofit SAT programs were significantly more likely to offer transitional/ancillary services than for-profit programs. However, programs that accepted Medicaid, regardless of ownership, were significantly more likely to offer most transitional/ancillary services. The data suggest that Medicaid may play a significant role in offering key transitional/ancillary services related to successful treatment outcome, regardless of program ownership type.

McCarty D; Perrin NA; Green CA; Polen MR; Leo MC; Lynch F. Methadone maintenance and the cost and utilization of health care among individuals dependent on opioids in a commercial health plan. Drug and Alcohol Dependence 111(3): 235-240, 2010. (18 refs.)

Background: Few health plans provide maintenance medication for opioid dependence. This study assessed the cost of treating opioid-dependent members in a commercial health plan and the impacts of methadone maintenance on costs of care. Methods: Individuals with diagnoses of opioid dependence (two or more diagnoses per year) and at least 9 months of health plan eligibility each year were extracted from electronic health records for the years 2000 through 2004 (1,518 individuals and 2,523 observations across the study period-some individuals were in multiple years) Analyses examined the patterns and costs of health care for three groups of patients (1) one or more methadone visits during the year (n = 1 298; 51%) (2) no methadone visits and 0 or 1 visits in the Addiction Medicine Department (n = 370 15%) (3) no methadone visits and 2 or more visits in addiction medicine (n = 855, 34%) Results: Primary care (86%) emergency department (48%) and inpatient (24%) visits were common. Mean total annual costs to the health plan were $11,200 (2004 dollars) per member per year. The health plan's costs for members receiving methadone maintenance were 50% lower ($7,163) when compared to those with two or more outpatient addiction treatment visits but no methadone ($14,157) and 62% lower than those with one or zero outpatient addiction treatment visits and no methadone treatment ($18, 694) Conclusions: Use of opioid maintenance services was associated with lower total costs of care for opioid-dependent members in a commercial health plan.

McConnell KJ; Gast SHN; Ridge MS; Wallace N; Jacuzzi N; Rieckmann T et al. Behavioral health insurance parity: Does Oregon's experience presage the national experience with the Mental Health Parity and Addiction Equity Act? American Journal of Psychiatry 169(1): 31-38, 2012. (20 refs.)

Objective: The Mental Health Parity and Addiction Equity Act of 2008 prohibits commercial group health plans from imposing spending and visit limitations for mental health and substance abuse services that are not imposed on medical-surgical services. The act also restricts the use of managed care tools that apply to behavioral health benefits in ways that differ from how they apply to medical-surgical benefits. The only precedent for this approach is Oregon's state parity law, which was implemented in 2007. The goal of this study was to estimate the effect of Oregon's parity law on expenditures for mental health and substance abuse treatment services. Method: The authors compared expenditures for commercially insured individuals in four Oregon health plans from 2005 through 2008 and a matched group of commercially insured individuals in Oregon who were exempt from parity. Using a difference-in-differences analysis, the authors analyzed the effect of comprehensive parity on spending for mental health and substance abuse services. Results: Increases in spending on mental health and substance abuse services after implementation of Oregon's parity law were almost entirely the result of a general trend observed among individuals with and without parity. Expenditures per enrollee for mental health and substance abuse services attributable to parity were positive, but they did not differ significantly from zero in any of the four plans. Conclusions: Behavioral health insurance parity rules that place restrictions on how plans manage mental health and substance abuse services can improve insurance protections without substantial increases in total costs.

McLellan AT. Considerations on performance contracting: A purchaser's perspective. (commentary). Addiction 106(10): 1731-1732, 2011. (4 refs.)

This editorial deals with what are seen as two essential-but often ignored-requirements for effective performance contracting. The first is that the ultimately desired (purchased) result should be observable (verifiable), truly valuable to the purchaser, and reasonably likely as a result of behaviors (services) by the treatment program. The most valuable performance criteria are patient outcomes with intrinsic public health value (e.g. abstinence, employment), but many of these desirable outcomes are quite distal to the programmatic behaviors that are expected to influence them; and this creates problems. Next most valuable are interim patient behaviors that occur early during care and that are logically linked to more distal outcomes. These could include active participation and provision of drug-free urines during out-patient treatment. Of note, performance criteria based on program behaviors such as completing a diagnostic assessment or timely filing of a treatment plan are not as predictably related to later patient outcomes-they rarely provide true value. A second requirement for effective performance contracting is that the desired (purchased) result should be linked closely in time to a reward that is large enough to change the contingent behavior. This may be the most important requirement for effective performance contracting, yet this is often ignored, invaryingly, with bad results. A purchaser might want 6-month post-treatment abstinence, and thus offer a performance contract that provides an extra $500 to a treatment program for every discharged patient who provides a drug-free urine at 6-month follow-up. This is an outcome with obvious public health value, and the performance measure (urine) is a reasonably valid indicator. However, there are three critical problems in the execution. First, any behaviors or actions that the program might undertake to meet the performance goal are at least 6 months removed from the performance criterion (post-treatment abstinence) and thus not likely to become engrained. Secondly, while treatment should be expected to reduce patient substance use while the patient is participating in out-patient care, it is debatable whether or for how long patient improvements will sustain after care is finished. Reliably, affecting that type of sustained outcome will probably require post-treatment services such as telephone monitoring, attendance at Alcoholics Anonymous and/or periodic home visits. This raises the third problem. Most addiction treatment programs do not have significant reserve resources, so an opportunity for larger, performance contingent rewards such as this will almost always require the program to invest capital in new procedures, personnel and training. In turn, the earned rewards will have to be sufficiently large and timely to pay off the investment outlay by the program-$500, 6 months post-discharge will probably not do it.

2011, Society for the Study of Addiction

McMenamin SB; Halpin HA; Bellows NM; Husten CG; Rosenthal A. State Medicaid coverage for tobacco-dependence treatments --- United States, 2007. MMWR. Morbidity and Mortality Weekly Review 58(43): 1199-1204, 2009. (10 refs.)

In 2007, the Center for Health and Public Policy Studies at the University of California, Berkeley, surveyed all 51 Medicaid programs. This report summarizes the results of that survey, which found that 43 (84%) programs offered coverage for some form of tobacco-dependence treatment to Medicaid enrollees in traditional fee-for-service (FFS) Medicaid, with four Medicaid programs adding coverage since 2006 and 20 programs adding coverage in the past decade. Only two states (New Mexico and New Jersey) reported access to tobacco-dependence treatments without any limitations or restrictions. Of the 25 states covering pharmacotherapy for Medicaid enrollees in both FFS and managed-care organizations (MCOs), only 13 covered the same tobacco-dependence treatments for enrollees in both populations. Research demonstrates that providing access to comprehensive tobacco-dependence treatments increases quit rates.

Public Domain

McMenamin SB; Halpin HA; Ingram M; Rosenthal A. State Medicaid coverage for tobacco-dependence treatments --- United States, 2009. MMWR. Morbidity and Mortality Weekly Review 59(41): 1340-1343, 2010. (10 refs.)

Medicaid enrollees have nearly twice the smoking rates (37%) of the general adult population (21%), and smoking-related medical costs are responsible for 11% of Medicaid expenditures (1,2). In 2008, the Public Health Service released clinical practice guidelines recommending comprehensive coverage of effective tobacco-dependence medications and counseling by health insurers. To monitor progress toward that objective, the Center for Health and Public Policy Studies at the University of California, Berkeley, in collaboration with CDC, surveyed Medicaid programs in the 50 states and the District of Columbia (DC) to document their 2009 tobacco-dependence treatment coverage and found that 47 programs offered coverage. Only eight state programs offered coverage of all recommended pharmacotherapy and counseling for all Medicaid enrollees, and 16 programs reported coverage for fee-for-service enrollees that differed from that provided for Medicaid managed-care enrollees. Among the 33 programs that covered at least one combination therapy, the nicotine patch plus bupropion slow release (SR) was the one combination covered by all.

Public Domain

Office of Applied Studies, Substance Abuse and Mental Health Services Administration. The N-SSATS Report: Free Substance Abuse Treatment. (April 15, 2010). Rockville MD: Substance Abuse and Mental Health Administration, 2010. (3 refs.)

The most common reason why individuals with substance use problems do not seek treatment is the financial burden imposed by a lack of health insurance or health insurance without a behavioral health benefit, and/or insufficient means to pay for treatment. Nevertheless, a review of admissions to substance abuse treatment in 2007 shows that nearly 60% of all admissions did not have health insurance of any kind. Treatment providers recognize that paying for treatment can be a burden to their clients. To help defray the costs of treatment, some facilities offer treatment at no charge and/or a sliding fee scale based on income and other factors. Data from the 2008 National Survey of Substance Abuse Treatment Services (N-SSATS) allows a comparison of facilities that offer free care with others that do not. Among the findings was that private non-profit organizations operated the majority of facilities offering "all free" care and "partial free" facilities (73.8 and 68.1%, respectively); among facilities offering "no free" care, approximately equal percentages were operated by private for-profit (46.9%) and private non-profit (46.4%) organizations. Facilities offering "all free" care (51.6%) were more likely than those in the "partial free" (30.5%) or "no free" (20.6%) groups to offer non- hospital residential care. "All free" facilities were less likely than either "partial free" or "no free" facilities to have a specially designed group or program for DUI/DWI clients (5.2 vs. 28.5 vs. 30.5%). Information is provided on the treatment services, treatment approaches, and special client groups served.

Public Domain

Office of Applied Studies, Substance Abuse and Mental Health Services Administration. The TEDS Report: Differences in Substance Abuse Treatment Admissions between Mexican-American Males and Females. (May 5, 2010). Rockville MD: Substance Abuse and Mental Health Administration, 2010. (5 refs.)

As the proportion of racial/ethnic minority groups within the United States continues to increase, it is important that public health professionals understand the specific characteristics and substance abuse behaviors of these populations. Hispanics not only account for almost 15% of the nation's population, but also comprise 15% of all substance abuse treatment admissions. Of particular interest are Hispanics of Mexican origin, who represent the majority (64.0%) of the nation's Hispanic population. Using data from TEDS for 2007, this report focuses on Hispanic substance abuse treatment admissions of Mexican origin (hereafter referred to as "Mexican") and highlights gender differences within this population. Among Mexican admissions, males reported alcohol as their primary substance of abuse more often than other substances, and females most commonly reported methamphetamine. The majority of Mexican admissions reported that they first used their primary substance of abuse before the age of 18 (60.7% for males and 56.1% for females); overall, 7.4% reported using their first substance before the age of 12. About three quarters of Mexican admissions had no health insurance (78.8% for males and 71.5% for females), a substantially higher proportion than non-Mexican admissions (62.6% for males and 50.9% for females).

Public Domain

Penz ED; Manns BJ; Hebert PC; Stanbrook MB. Governments, pay for smoking cessation. (editorial). Canadian Medical Association Journal 182(18): E810-E810, 2010. (5 refs.)

Pesis-Katz I; Williams GC; Niemiec CP; Fiscella K. Cost-effectiveness of intensive tobacco dependence intervention based on self-determination theory. American Journal of Managed Care 17(10): E393-E398, 2011. (27 refs.)

Objectives: To evaluate cost-effectiveness of a tobacco dependence intervention based on self-determination theory (SDT) and consistent with the Public Health Service (PHS)-sponsored Clinical Practice Guideline for Treating Tobacco Use and Dependence. Study Design: Adult smokers were recruited into a randomized cessation-induction trial of an intensive intervention versus community care. Seven-day point prevalence (7dPP) tobacco abstinence and cost-effectiveness of the intervention were examined using 737 participants with health insurance. Methods: Community care (CC) participants received smoking-cessation pamphlets and information on local treatment programs. Intervention participants received those materials and were asked to meet 4 times over 6 months with study counselors to discuss their health in a manner that supported autonomy and perceived competence. The third-party payer's perspective was used for this analysis, and the primary outcome was cost-effectiveness using self-reported 7dPP tobacco abstinence at 6 months. Sensitivity analyses were performed using costs of generic medications, biochemically validated tobacco abstinence, actual rates of tobacco abstinence, life-years saved (not adjusted for quality of life), and costs in 2011 US dollars. A subgroup analysis was conducted using smokers who did not want to stop within 30 days. Results: Smokers in the intervention, relative to CC, were more likely to attain 7dPP tobacco abstinence at 6 months. The overall incremental cost-effectiveness ratio was $1258 per quality-adjusted life-year saved, in US dollars. The sensitivity and subgroup analyses yielded similar results. Conclusions: An intervention based on SDT and consistent with the PHS Guideline facilitated tobacco abstinence among insured smokers and was cost-effective compared with other tobacco dependence and medical interventions.

Peterson JA; Schwartz RP; Mitchell SG; Reisinger HS; Kelly SM; O'Grady KE et al. Why don't out-of-treatment individuals enter methadone treatment programmes? International Journal of Drug Policy 21(1): 36-42, 2010. (54 refs.)

Background: Despite the proven effectiveness of methadone treatment, the majority of hero in-dependent individuals are out-of-treatment. Methods: Twenty-six opioid-dependent adults who met the criteria for methadone maintenance who were neither seeking methadone treatment at the time of study enrollment, nor had participated in such treatment during the past 12 months, were recruited from the streets of Baltimore, Maryland through targeted sampling. Ethnographic interviews were conducted to ascertain participants' attitudes toward methadone treatment and their reasons for not seeking treatment. Results: Barriers to treatment entry included: waiting lists, lack of money or health insurance, and requirements to possess a photo identification card. For some participants, beliefs about methadone such as real or rumored side effects, fear of withdrawal from methadone during an incarceration, or disinterest in adhering to the structure of treatment programmes kept them from applying. In addition, other participants were not willing to commit to indefinite "maintenance" but would have accepted shorter time-limited methadone treatment. Conclusion: Barriers to treatment entry could be overcome by an infusion of public financial support to expand treatment access, which would reduce or eliminate waiting lists, waive treatment-related fees, and/or provide health insurance coverage for treatment. Treatment programmes could overcome some of the barriers by waiving their photo I.D. requirements, permitting time-limited treatment with the option to extend such treatment upon request,and working with corrections agencies to ensure continued methadone treatment upon incarceration.

Pyenson BS; Sander MS; Jiang YD; Kahn H; Mulshine JL. An actuarial analysis shows that offering lung cancer screening as an insurance benefit would save lives at relatively low cost. Health Affairs 31(4): 770-779, 2012. (30 refs.)

Lung cancer screening is not established as a public health practice, yet the results of a recent large randomized controlled trial showed that screening with low-dose spiral computed tomography reduces lung cancer mortality. Using actuarial models, this study estimated the costs and benefits of annual lung cancer screening offered as a commercial insurance benefit in the high-risk US population ages 50-64. Assuming current commercial reimbursement rates for treatment, we found that screening would cost about $1 per insured member per month in 2012 dollars. The cost per life-year saved would be below $19,000, an amount that compares favorably with screening for cervical, breast, and colorectal cancers. Our results suggest that commercial insurers should consider lung cancer screening of high-risk individuals to be high-value coverage and provide it as a benefit to people who are at least fifty years old and have a smoking history of thirty pack-years or more. We also believe that payers and patients should demand screening from high-quality, low-cost providers, thus helping set an example of efficient system innovation.

Reda AA; Kaper J; Fikrelter H; Severens JL; van Schayck CP. Healthcare financing systems for increasing the use of tobacco dependence treatment. (review). Cochrane Database of Systematic Reviews 2009(2): article CD004305, 2009. (56 refs.)

Background: We hypothesized that provision of financial assistance for smokers trying to quit, or reimbursement of their care providers, could lead to an increased rate of successful quit attempts. Objectives The primary objective of this review was to assess the impact of reducing the costs of providing or using smoking cessation treatment by health care financing interventions on abstinence from smoking and utilization of smoking cessation treatment. Search strategy: We searched the Cochrane Tobacco Addiction group specialized register; the Cochrane Central Register of Controlled Trials (CENTRAL) Issue 3, 2008; MEDLINE (from January 1966 to August 2008) and EMBASE (from January 1980 to August 2008) to identify trials. Selection criteria: We included randomized controlled trials (RCTs) and controlled trials involving financial benefit interventions to smokers or their health care providers or both. Data collection and analysis: Three reviewers independently extracted data and assessed the quality of the included studies. Rate ratios (RR) were calculated for individual studies on an intention-to-treat basis and meta-analysis was performed using a random effects model. We included economic evaluations when a study presented the costs and effects of two or more alternatives. Main results: We found nine trials involving financial interventions directed at smokers and two studies directed at health care providers. There was a statistically significant favourable effect of full financial interventions directed at smokers on continuous abstinence compared to no interventions with a risk ratio (RR) of 4.38 (95% CI 1.94 to 9.87). There was also a significant effect of full financial interventions when compared to no interventions on the number of participants making a quit attempt (RR 1.19; 95% CI 1.07 to 1.32; N = 3). There was a significant effect of financial interventions directed at health care providers in increasing the utilization of behavioural interventions for smoking cessation (RR 1.33; 95% CI 1.01 to 1.77). Comparison of full benefit with partial or no benefit resulted in costs per additional quitter ranging from $260 to $1453. Authors' conclusions: Full financial interventions directed at smokers when compared to no financial interventions could increase the proportion quitting, quit attempts and utilization of pharmacotherapy by smokers. Although the absolute differences were small the costs per additional quitter were low. The methodological qualities of the included studies need to be taken into consideration in interpreting the conclusions.

Risser J; Cates A; Rehman H; Risser W. Gender differences in social support and depression among injection drug users in Houston, Texas. American Journal of Drug and Alcohol Abuse 36(1): 18-24, 2010. (34 refs.)

Background: Injection drug is the second most frequent HIV/AIDS exposure in the United States. Social support and depression may mediate risky behaviors among drug injectors. Objectives: To describe differences in perceived social support and depressive symptoms between male and female injection drug users, and to describe factors associated with depressive symptoms. Methods: Using respondent-driven sampling, we recruited and interviewed injection drug users in Houston, Texas. Data were from the Centers for Disease Control and Prevention's National HIV Behavioral Surveillance Program. We used the short Center for Epidemiologic Studies Depression Scale (CES-D 10) and scales for perceived social support from family, friends, and significant others from the Multidimensional Scale of Perceived Social Support. Four-hundred seventy-one participants had complete data and were included in this analysis. Results: Seventy-five percent of male and female participants had CES-D scores indicating depressive symptoms. In a multivariate logistic regression, depressive symptoms among men were positively associated with frequent use of speedballs (injecting heroin and cocaine together) and never having tested for HIV, and negatively associated with perceived social support from a special person. Among women, depressive symptoms were positively associated with currently smoking cigarettes, having no health insurance, and more years of injection drug use, and negatively associated with perceived social support from a special person. Conclusions: Lack of social support from a special person or significant other was associated with depressive symptoms in both males and females. Our findings suggest that depression and social support should be addressed when developing HIV prevention programs among injection drug users.

Roy K; Miller M. Parity and the medicalization of addiction treatment. Journal of Psychoactive Drugs 42(2): 115-120, 2010. (0 refs.)

Parity, the idea that insurance coverage for the treatment of addiction should be on a par with insurance coverage for the treatment of other medical illnesses, is not a new idea, but the path to achieving "real parity" has been a long, hard and complex journey. Action by Congress to pass major parity legislation in 2008 was a huge step forward, but does not mean that parity has been achieved. Parity has required a paradigm shift in the understanding of addiction as a biological illness: many developments of science and policy changes by professional organizations and governmental entities have contributed to that paradigm shift. Access to adequate treatment for patients must acknowledge the paradigm shift reflected in parity as it has evolved to the current point: that this biological illness is widespread, that it is important that it be treated effectively, that appropriate third party payment for physician-provided or physician-supervised addiction treatment is critical for addiction medicine to become a part of the mainstream of our nation's healthcare delivery system, and that medical specialty care provides the most effective and cost effective benefit to patients and therefore to our society.

Ruetsch C. Empirical view of opioid dependence. Journal of Managed Care Pharmacy 16(1, Supplement B): s9-s13, 2010. (28 refs.)

BACKGROUND: The impact of opioid dependence on employers, managed care, and society is significant. Inappropriate use of narcotic analgesics leads to uncontrolled pain management, dependence, and may lead to patient deaths, creating a tremendous cost burden to the health care system. OBJECTIVE: To provide an overview of the clinical and economic impact of treating opioid dependence on managed care, employers, and society. SUMMARY: An estimated 6% to 15% of people in the United States abuse drugs, and approximately 20% of Americans report using prescription opioids for nonmedical use. This is associated with an annual cost of nearly half a trillion dollars, taking into account the medical, economic, social, and criminal impact of this abuse. A recent study showed that patients who abuse opioids generate mean annual direct health care costs 8.7 times higher than nonabusers. The National Survey on Drug Use and Health (NSDUH), conducted by the Substance Abuse and Mental Health Services Administration (SAMHSA), found that patients who report opioid abuse miss more than 2.2 days of work monthly, compared with the 0.83 days per month reported for the average person. Presenteeism and productivity are also affected by misuse and dependence on opioids. CONCLUSION: The costs associated with opioid dependence are significant. Physicians, employers, and managed care organizations must be proactive in appropriately diagnosing and treating patients who suffer from substance abuse disorders in order to lessen this economic burden.

Shern DL; Beronio KK; Harbin HT. After parity: What's next. Health Affairs 28(3): 660-662, 2009. (5 refs.)

A new law prohibiting unequal treatment limits and financial requirements for mental health and substance abuse (MH/SA) benefits establishes critical protections for 113 million Americans. The new parity law doesn't mandate coverage for MH/SA treatment and anticipates management of the benefit. Given these features, clear regulations mapping the intent of the law are critical. Education regarding the costs of untreated or ineffectively treated MH/SA conditions is needed to encourage comprehensive coverage, because academic performance and worker productivity are at stake. As health care reform proceeds, we must use the new law to reinforce the centrality of mental health to overall health.

Smaldone A; Cullen-Drill M. Mental health parity legislation understanding the pros and cons. Journal of Psychosocial Nursing and Mental Health Services 48(9): 26-34, 2010. (21 refs.)

Although recognition and treatment of mental health disorders have become integrated into routine medical care, inequities remain regarding limits on mental health outpatient visits and higher copayments and deductibles required for mental health services when accessed. Two federal laws were passed by Congress in 2008: The Paul Wellstone and Pete Domenici Mental Health Parity and Addiction Equity Act and the Medicare Improvements for Patients and Providers Act. Both laws became effective on January 1, 2010. The purpose of this article is to discuss provisions of each act and provide clinical examples describing how patients are affected by lack of parity and may potentially benefit from implementation of these new laws. Using available evidence, we examine the potential strengths and limitations of mental health parity legislation from the health policy perspectives of health care access, cost, and quality and identify the important role of nurses as patient and mental health parity advocates.

Smith DE; Lee DR; Davidson LD. Health care equality and parity for treatment of addictive disease. Journal of Psychoactive Drugs 42(2): 121-126, 2010. (32 refs.)

Substance abuse represents a significant underlying cause of the health issues faced in the United States, which severely impacts the nation's health care system and economy. Recently enacted parity legislation mandates that benefits for addiction and mental health treatment be provided on an equal footing with those for treatment for physical health. Diversion and abuse of prescription medications is growing in young people, with much of the diversion occurring between family and friends. Addiction has been accepted by mainstream medicine as a brain disease, and is associated with many other medical disorders. Early intervention and treatment for addiction provides extraordinary cost-benefit outcomes. Additional training for addiction professionals will be necessary. Stigmatization of substance abusers continues to exist at the state and federal levels, although research during the past 10 years indicates that patient compliance and relapse rates for substance abusers are not significantly different than those for individuals with other chronic diseases, e.g. diabetes, hypertension, and cardiac issues. While parity for addiction treatment has become policy at the federal level, great challenges lie ahead in funding access, facilities, and training, as well as redirecting societal perceptions and legislated penalties.

Sterling S; Weisner C; Hinman A; Parthasarathy S. Access to treatment for adolescents with substance use and co-occurring disorders: Challenges and opportunities. (review). Journal of The American Academy of Child and Adolescent Psychiatry 49(7): 637-646, 2010. (76 refs.)

Objective: To review the research on economic and systemic barriers faced by adolescents needing treatment for alcohol and drug problems, particularly those with co-occurring conditions. Method: We reviewed the literature on adolescent access to alcohol and drug services, including early intervention, and integrated and specialty mental health treatment for those with co-occurring disorders, examining the role of health care systems, public policy (health reform), treatment financing and reimbursement systems (public and private), implementation of evidence-based practices, confidentiality practices, and treatment costs and cost/benefits. Results: Barriers to treatment, particularly integrated treatment, are largely rooted in our organizationally fragmented health care system, which encompasses public and private, carved-out and integrated systems, and different funding mechanisms (Medicaid versus block grants versus private insurance that include "high deductible" plans and other cost controls.) In both systems, carved-out programs de-link services from other mental health and general health care. Barriers are also rooted in disciplinary differences and weak clinical linkages between psychiatry, primary care and substance use, and in confidentiality policies that inhibit communication and coordination, while protecting patient privacy. Conclusion: In this era of health care reform, we have the opportunity to increase access for adolescents and develop new models of integrated services for those with co-occurring conditions. We discuss opportunities for improving treatment access and implementation of evidence-based practices, examine implications of health reform and parity legislation for psychiatric and substance use treatment, and comment on key unanswered questions and future research opportunities.

Taylor M; Leonardi-Bee J; Agboola S; McNeill A; Coleman T. Cost effectiveness of interventions to reduce relapse to smoking following smoking cessation. Addiction 106(10): 1819-1826, 2011. (35 refs.)

Aims To determine the incremental cost effectiveness of nicotine replacement therapy (NRT), bupropion and varenicline for preventing relapse to smoking when used by abstinent smokers Design setting and participants Cohort simulation and sensitivity analyses combining cost and health service data with systematic review estimates for the effectiveness of NRT, bupropion and varenicline when used by abstinent quitters to prevent their relapse to smoking. Measurements Incremental health gain in Quality Adjusted Life Years (QALYs) generated by each drug compared to 'no intervention'. Findings Bupropion resulted in an incremental QALY increase of 0.07 with a concurrent cost saving of 68; pound NRT and varenicline both caused incremental QALYs increases of 0.04 at costs of 12 pound and 90 pound respectively, although varenicline findings were based on data from a single clinical trial and require cautious interpretation. Even after extensive sensitivity analyses with substantial varying of key model parameters, cost effectiveness of all drugs remained. Cost effectiveness ratios only exceeded the UK National Institute of Clinical Excellence (NICE) benchmark of 20 pound 000 per QALY when drug treatment effects were postulated to last for no longer than 1 year; or, for NRT and varenicline, efficacy was reduced to 10% of that observed in clinical trials. Conclusions: Bupropion, nicotine replacement therapy and varenicline appear cost effective at preventing relapse to smoking by smokers who are in quit attempts and have recently become abstinent; they have comparable cost effectiveness to smoking cessation interventions. Widespread use of these effective relapse prevention treatments could promote substantial health gain at an acceptable cost to health providers.

Terplan M; Smith EJ; Glavin SH. Trends in Injection Drug Use Among Pregnant Women Admitted into Drug Treatment: 1994-2006. Journal of Women's Health 19(3): 499-505, 2010. (31 refs.)

Objective: To describe trends in the regional and demographic characteristics of injection drug use (IDU) during pregnancy. Methods: Data were obtained from the Treatment Episode Data Set (TEDS), an administrative data set that captures admissions to federally funded treatment centers in the United States. Demographic and treatment-related measures were examined and compared between injection drug and noninjection drug admissions. The results were stratified by year of admission to assess trends over time. Results: From 1994 to 2006, there were 239,511 admissions of pregnant women, of whom 34,717 (14.4%) reported IDU. There was little change in the proportion of injecting from year to year. Compared with admissions of noninjecting pregnant women, a greater proportion of injection drug users were white (68.5 vs. 48.6%), reported heroin use (70.0% vs. 13.2%), and had no health insurance (48.2% vs. 40.2%). Over the time period, the proportion of injection drug users was seen to spread from the West to the South and Northeast for heroin and to the Midwest for amphetamines. Conclusions: IDU among pregnant women in drug treatment remains a significant public health issue, especially among white women.

Terry-McElrath YM; Chriqui JF; McBride DC. Factors related to medicaid payment acceptance at outpatient substance abuse treatment programs. Health Services Research 46(2): 632-653, 2011. (36 refs.)

Objective: To examine factors associated with Medicaid acceptance for substance abuse (SA) services by outpatient SA treatment programs. Data Sources: Secondary analysis of 2003-2006 National Survey of Substance Abuse Treatment Services data combined with state Medicaid policy and usage measures and other publicly available data. Study Design: We used cross-sectional analyses, including state fixed effects, to assess relationships between SA treatment program Medicaid acceptance and (1) program-level factors, (2) county-level sociodemographics and treatment program density, and (3) state-level population characteristics, SA treatment-related factors, and Medicaid policy and usage. Data Extraction Methods: State Medicaid policy data were compiled based on reviews of state Medicaid-related statutes/regulations and Medicaid plans. Other data were publicly available. Principal Findings: Medicaid acceptance was significantly higher for programs: (a) that were publicly funded and in states with Medicaid policy allowing SA treatment coverage; (b) with accreditation/licensure and nonprofit/government ownership, as well as mental- and general-health focused programs; and (c) in counties with lower household income. Conclusions: SA treatment program Medicaid acceptance related to program-, county, and state-level factors. The data suggest the importance of state policy and licensure/accreditation requirements in increasing SA program Medicaid access.

Tsai J; Floyd RL; Green PP; Denny CH; Coles CD; Sokol RJ. Concurrent alcohol use or heavier use of alcohol and cigarette smoking among women of childbearing age with accessible health care. Prevention Science 11(2): 197-206, 2010. (76 refs.)

This study was conducted to provide nationally representative findings on the prevalence and distribution of concurrent alcohol use or heavier use of alcohol and cigarette smoking among women of childbearing age with accessible health care. For the years 2003-2005, a total of 20,912 women 18-44 years of age who participated in the National Health Interview Survey (NHIS) reported that during the study period, there was a place where they would usually go for health care when sick or in need of advice about their health. The prevalence and distribution of concurrent alcohol use or heavier use of alcohol and cigarette smoking reported by such women was calculated. Logistic regression analysis was used to evaluate the "most often visited health care place" among concurrent users who reported having seen or talked to a health care provider during the previous 12 months. Among surveyed women with accessible health care, 12.3% reported concurrent alcohol use and cigarette smoking, and 1.9% reported concurrent heavier use of alcohol and cigarette smoking during the study period. Of women who reported either type of concurrent use, at least 84.4% also indicated having seen or talked to one or more health care providers during the previous 12 months. Such women were more likely than non-concurrent users to indicate that the "most often visited health care place" was a "hospital emergency room or outpatient department or some other place" or a "clinic or health center," as opposed to an "HMO or doctor's office." Concurrent alcohol use or heavier use of alcohol and cigarette smoking among women of childbearing age is an important public health concern in the United States. The findings of this study highlight the importance of screening and behavioral counseling interventions for excessive drinking and cigarette smoking by health care providers in both primary care and emergency department settings.

Tsiachristas A; Hipple-Walters B; Lemmens KMM; Nieboer AP; Rutten-van Molken MPMH. Towards integrated care for chronic conditions: Dutch policy developments to overcome the (financial) barriers. Health Policy 101(2): 122-132, 2011. (51 refs.)

Chronic non-communicable diseases are a major threat to population health and have a major economic impact on health care systems. Worldwide, integrated chronic care delivery systems have been developed to tackle this challenge. In the Netherlands, the recently introduced integrated payment system - the chain-DTC - is seen as the cornerstone of a policy stimulating the development of a well-functioning integrated chronic care system. The purpose of this paper is to describe the recent attempts in the Netherlands to stimulate the delivery of integrated chronic care, focusing specifically on the new integrated payment scheme and the barriers to introducing this scheme. We also highlight possible threats and identify necessary conditions to the success of the system. This paper is based on a combination of methods and sources including literature, government documents, personal communications and site visits to disease management programs (DMPs). The most important conditions for the success of the new payment system are: complete care protocols describing both general (e.g. smoking cessation, physical activity) and disease-specific chronic care modules, coverage of all components of a DMP by basic health care insurance, adequate information systems that facilitate communication between care-givers, explicit links between the quality and the price of a DMP, expansion of the amount of specialized care included in the chain-DTC, inclusion of a multi-morbidity factor in the risk equalization formula of insurers, and thorough economic evaluation of DMPs.

Vandivort R; Teich JL; Cowell AJ; Chen H. Utilization of substance abuse treatment services under Medicare, 2001-2002. Journal of Substance Abuse Treatment 36(4): 414-419, 2009

In 2006, the Medicare program covered 37 million elderly persons and 7 million persons younger than 65 years, but little is known about substance abuse (SA) service utilization. Using the 5% Sample of Medicare claims data, the study examines individuals who used SA detoxification ("detox") and/or rehabilitation ("rehab") services under Medicare in 2001 and 2002. SA claimants less than 65 years of age (disabled) were compared to claimants more than 65 years of age (elderly). The disabled were more likely to have a co-occurring mental disorder than elderly claimants (50% vs. 14%) and more likely to have serious mental illness (21% vs. 2.3%). Disabled claimants were more than three times as likely to receive any detox service as elderly claimants (17% vs. 6%). The rate of claimants receiving rehab services within 30 days of detox is about one third for disabled claimants and one quarter for elderly claimants.

Walls SJ. The need for special Veteran Courts. Denver Journal of International Law and Policy 39: 695, 2011. (294 legal refs.)

... While the effects of TBI on the mental processes are potentially as serious as the effects of PTSD on the mental processes of the returning soldiers, this article will exclusively discuss the relation between PTSD, service in combat, and criminal behavior. ... Although society recognized combat stress as a natural consequence of war, the effects of combat stress on veterans was not a focus of societal concern until the end of the Vietnam War. ... The psychological state of the Vietnam veteran was misunderstood, and many thought that individuals who served as soldiers were predisposed to mental health issues, substance abuse, and criminal behavior. ... Veteran Specialty Courts are courts that use alternative prosecution and sentencing methods to treat the underlying PTSD diagnosis and substance abuse problems. ... Society, through taxes, bears the cost of caring for veterans of war through treatment of physical and psychological wounds and by providing social services to the veterans whom do not seek care and suffer from prolonged PTSD symptoms, such as homelessness, suicides, drug abuse, or incarceration. ... Despite the reduced percentage of British soldiers suffering from PTSD, the research concluded that substance abuse problems were fewer among United States soldiers than among British soldiers. ... In response to the NAPO report, the following year the Veterans Parliamentary Group produced the Coordinated National Action Plan (Plan) to implement a national strategy to deal address the large number of British forces that are incarcerated or are in probation's control.

Wells R; Morrissey JP; Lee IH; Radford A. Trends in behavioral health care service provision by community health centers, 1998-2007. Psychiatric Services 61(8): 759-764, 2010. (26 refs.)

Objective: The federal government boosted support for community health centers in medically underserved areas in 2002-2007. This investigation compared trends in behavioral health services provided by community health centers nationwide during the first several years of that initiative with immediately prior trends. Methods: Data were extracted from the Health Resources and Services Administration's Uniform Data System on community health centers for 1998-2007 (2007, N=1,067). Regression analyses revealed trends in individual community health centers' likelihood of providing on-site specialty mental health care, crisis services, and substance abuse treatment. Aggregate data were used to show national trends in numbers of behavioral health encounters, patients, and encounters per patient. Results: The number of federally funded community health centers increased 43% between 2001 and 2007, from 748 to 1,067, over twice the annual growth rate between 1998 and 2001. However, trends in individual community health centers' likelihood of providing different types of behavioral health care were generally consistent across the two time periods. In 2007, 77% of community health centers offered specialty mental health services, 20% offered 24-hour crisis intervention services, and 51% offered substance abuse treatment. The mean number of mental health encounters per mental health patient at community health centers in 2007 was 2.9. Conclusions: The behavioral health care safety net has widened through rapid recent growth in the number of community health centers as well as a continuing increase in the proportion offering specialty mental health services.

Wickizer TA; Mancuso D; Campbell K; Lucenko B. Evaluation of the Washington State Access to Recovery project: Effects on Medicaid costs for working age disabled clients. Journal of Substance Abuse Treatment 37(3): 240-246, 2009. (31 refs.)

In 2004, the federal government made a major commitment to support expanded substance abuse (SA) recovery services by initiating the Access to Recovery (ATR) program. The initial ATR I program awarded grants to 14 states, including Washington State. We evaluated Washington's ATR I program to determine its effect on Medicaid costs for working age disabled clients. We compared per member per month (PMPM) Medicaid costs during 1 year follow-up for clients who received ATR services (N = 1,347) with costs for a matched comparison group of 1,243 clients and used multiple regression techniques to estimate changes in Medicaid costs associated with ATR. ATR was found to be associated with reductions in PMPM Medicaid costs of $66 (p = 11) to $136 (p = .05) depending upon months of Medicaid eligibility. Recovery services aimed at facilitating engagement in SA treatment and aftercare appear to foster modest savings in Medicaid costs for working age disabled clients.

Zeng F; Chen CI; Mastey V; Zou KH; Harnett J; Patel BV. Effects of copayment on initiation of smoking cessation pharmacotherapy: An analysis of varenicline reversed claims. Clinical Therapeutics 33(2): 225- 234, 2011. (34 refs.)

Background: Smoking cessation pharmacotherapy is a critical component of smoking cessation treatment, but most smokers use neither pharmacotherapy nor behavior counseling in attempts to quit smoking. The low rate of smoking cessation medication use is of great concern because it can negatively influence the odds of success in smoking cessation. Objective: This study was conducted to analyze how copayment may influence the likelihood of initiating smoking cessation pharmacotherapy following a reversed varenicline claim. Methods: A retrospective cohort analysis was performed using pharmacy claims data from a large national pharmacy benefits management company. Reversed claims were claims first approved by the health plan and then reversed by the pharmacy. The study population included patients with over-the-counter nicotine replacement therapy coverage and a reversed varenicline claim between January 2007 and April 2008 and who were naive to varenicline before the reversed claim. A multivariate logistic regression analysis was conducted to evaluate the probability of initiating any smoking cessation pharmacotherapy (varenicline, bupropion, and prescribed or over-the-counter nicotine replacement therapy) within 183 days of the reversed claim. Results: A total of 20,451 patients met the inclusion criteria. The mean (SD) age of patients was 47.8 (12.4) years, with 57.41% being female. The majority (87.72%) were covered in commercial managed care plans. A total of 17,028 patients (83.26%) had at least 1 smoking cessation medication filled 6 months after their reversed claim. The odds ratios for patients who had any smoking cessation medication filled and copayments of $31 to $40, $41 to $60, or >$60 were 0.68, 0.48, and 0.35, respectively (all, P < 0.001), compared with patients with copayments of $0 to $5. Conclusions: The findings suggest that some patients might have been deterred by a high copayment (>= $31) and, ultimately, did not fill any smoking cessation treatments within 183 days of reversed varenicline claims. It is important to address this potential treatment gap to improve the effectiveness of smoking cessation therapy.

Ziller EC; Anderson NJ; Coburn AF. Access to rural mental health services: Service use and out-of-pocket costs. Journal of Rural Health 26(3): 214-224, 2010. (28 refs.)

Purpose: To examine rural-urban differences in the use of mental health services (mental health and substance abuse office visits, and mental health prescriptions) and in the out-of-pocket costs paid for these services. Methods: The pooled 2003 and 2004 Medical Expenditure Panel Surveys were used to assess differences in mental health service use by rural and urban residence and average per person mental health expenditures by payer and by service type. Findings: Study findings reveal a complicated pattern of greater need among rural than urban adults for mental health services, lower rural office-based mental health use and higher rural prescription use, and no rural-urban differences in total or out-of-pocket expenditures for mental health services. Conclusions: These findings raise questions about the appropriateness and quality of mental health services being delivered to rural residents. Lower mental health spending among rural residents is likely explained by lower use of psychotherapy and other office-based services, but it may also be related to these services being delivered by lower-cost providers in rural areas. Findings suggest that an approach focusing on reducing underinsurance for all health services among rural residents may help to reduce unmet mental health needs among the rural privately insured.

Zuvekas SH; Meyerhoefer CD. State variations in the out-of-pocket spending burden for outpatient mental health treatment. Health Affairs 28(3): 713-722, 2009. (19 refs.)

We examine the potential of mental health/substance abuse (MH/SA) parity laws to reduce the out-of-pocket spending burden for outpatient treatment at the state level by exploring cross-state variations and their causes, as well as the provisions of MH/SA parity laws. We find modest (yet important) variation in out-of-pocket burden across states overall, but -- because prescription medications account for two-thirds of out-of-pocket spending and are generally beyond the scope of recently enacted federal parity laws -- evidence suggests that those laws will do little to reduce the observed burden or its variation. Other policy measures, designed to expand and improve health insurance coverage or reduce racial/ethnic disparities, could have a more profound impact.