Background The Centers for Disease Control and Prevention (CDC) issued guidelines and certain healthcare payers have made pharmacy coverage changes (PCC) focusing on regulating prescription opioids. Aim We evaluated differences in the rate of first-time opioid fills at doses ≥ 50 morphine milligram equivalents (MME)/day and first-time opioid fills with benzodiazepine fill overlap following the CDC guidelines and following a PCC between provider types, geographic locations, and insurance types. Method We used OptumLabs® Data Warehouse claims data between 2014 and 2018. Subjects were opioid naïve non-cancer care patients, 18 years and older who had an identified chronic pain condition ICD diagnosis within 2 weeks prior to their first-time opioid fill. We used multiple treatment period segmented regression analysis with interaction terms to test the differences between primary care providers (PCPs) and specialist providers (SPs), urban and rural primary care service areas (PCSAs), and Medicare Advantage (MA) and commercially insured patients (CIPs) in their first-time opioid fill patterns. Results Prescribing first-time opioid fills at doses ≥ 50MME/day declined following the CDC guidelines and PCC, the decline was greater among SPs than PCPs and in rural PCSAs than urban PCSAs. Also, following the CDC guidelines, the decline was greater among MA patients however following the PCC the decline was greater among CIPs. There were no differences in rate of first-time opioid fill with benzodiazepine overlap between groups. Conclusion Responses to the CDC opioid guidelines and a PCC differed between PCPs and SPs, urban and rural PCSAs, and when prescribing to MA and CIPs. Understanding these differences is important to help inform future guidelines. Supplementary Information The online version contains supplementary material available at 10.1007/s11096-021-01360-w.
BACKGROUND: Due to the US opioid epidemic, in March of 2016, the Centers for Disease Control and Prevention (CDC) published new guidelines for primary care providers on opioid prescribing for chronic pain. Payer coverage changes were also implemented to help modify opioid prescribing behavior. Whether these initiatives were associated with changes in opioid initiation patterns is unknown. OBJECTIVE: To assess the association between 3 of the 2016 CDC guidelines and 2 subsequent payer pharmacy coverageWhat is already known about this subject • The CDC guidelines were recommended for primary care providers.
Background: Lack of affordable health care affects the uninsured, commercially insured, and Medicare beneficiaries. Yet, the wide variation in providers’ prices and practice styles suggests that more affordable care already may be available and data on low value and wasteful care suggest that lower cost care need not come at the expense of better quality. Although price variation has received the most attention in the literature and legislation, total cost of care is a function of both unit prices (fees) and the quantity of services. Objective: To partition provider-specific variation in total annual risk-adjusted per capita expenditures on health care services into variation in unit prices (fees) versus quantities of services, and to explore the relationship between low value, avoidable, discretionary, and recommended care to total health expenditures. The analysis is important because both prices and quantities of services can affect affordability and reductions in prices versus quantities have very different effects on providers’ profits. Setting: 2018 data from the Minnesota State Employees Group Insurance Program (SEGIP) that offers a tiered cost-sharing health insurance benefit design to 130,000 State employees and their dependents (SEGIP “members”). Exposure: Each year during open enrollment, SEGIP members choose a primary care clinic (PCC). The PCC can make decisions regarding both unit prices and prescribed services. PCCs are placed in one of four cost-sharing tiers based on the total annual risk-adjusted per capita health expenditures for the SEGIP members who choose their clinic. Members choosing higher cost PCCs face higher deductibles, copayments, and maximum out-of-pocket spending limits. Measures: Overall prices and use of inpatient, outpatient hospital, professional, and pharmaceutical services, total and avoidable use of emergency department visits and inpatient admissions, low value care, testing for patients with pneumonia, and recommended preventive care. Results: Differences in total risk-adjusted annual per capita health expenditures across the care systems were substantial. Higher cost providers had both higher unit prices and higher use of services. Variation in the quantity of health care services explained more of the variance in total spending than variation in prices. Prices for professional services and use of inpatient, outpatient hospital, and pharmaceutical services, and ambulatory care sensitive admissions, contributed significantly to high total expenditures. Lower cost PCCs in the lowest cost-sharing tier had higher rates of low value care and lower emergency department visits per capita. Neither the number of investigations for patients with pneumonia nor the receipt of recommended mammography screening varied systematically by tier. Conclusions: Efforts to identify and expand sources of affordable care, including improved information and incentives for consumers, need to account for variation in both prices and quantities of services. Efforts to encourage more eff...
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