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1.  Proceedings of the 14th annual conference of INEBRIA 
Holloway, Aisha S. | Ferguson, Jennifer | Landale, Sarah | Cariola, Laura | Newbury-Birch, Dorothy | Flynn, Amy | Knight, John R. | Sherritt, Lon | Harris, Sion K. | O’Donnell, Amy J. | Kaner, Eileen | Hanratty, Barbara | Loree, Amy M. | Yonkers, Kimberly A. | Ondersma, Steven J. | Gilstead-Hayden, Kate | Martino, Steve | Adam, Angeline | Schwartz, Robert P. | Wu, Li-Tzy | Subramaniam, Geetha | Sharma, Gaurav | McNeely, Jennifer | Berman, Anne H. | Kolaas, Karoline | Petersén, Elisabeth | Bendtsen, Preben | Hedman, Erik | Linderoth, Catharina | Müssener, Ulrika | Sinadinovic, Kristina | Spak, Fredrik | Gremyr, Ida | Thurang, Anna | Mitchell, Ann M. | Finnell, Deborah | Savage, Christine L. | Mahmoud, Khadejah F. | Riordan, Benjamin C. | Conner, Tamlin S. | Flett, Jayde A. M. | Scarf, Damian | McRee, Bonnie | Vendetti, Janice | Gallucci, Karen Steinberg | Robaina, Kate | Clark, Brendan J. | Jones, Jacqueline | Reed, Kathryne D. | Hodapp, Rachel M. | Douglas, Ivor | Burnham, Ellen L. | Aagaard, Laura | Cook, Paul F. | Harris, Brett R. | Yu, Jiang | Wolff, Margaret | Rogers, Meighan | Barbosa, Carolina | Wedehase, Brendan J. | Dunlap, Laura J. | Mitchell, Shannon G. | Dusek, Kristi A. | Gryczynski, Jan | Kirk, Arethusa S. | Oros, Marla T. | Hosler, Colleen | O’Grady, Kevin E. | Brown, Barry S. | Angus, Colin | Sherborne, Sidney | Gillespie, Duncan | Meier, Petra | Brennan, Alan | de Vargas, Divane | Soares, Janaina | Castelblanco, Donna | Doran, Kelly M. | Wittman, Ian | Shelley, Donna | Rotrosen, John | Gelberg, Lillian | Edelman, E. Jennifer | Maisto, Stephen A. | Hansen, Nathan B. | Cutter, Christopher J. | Deng, Yanhong | Dziura, James | Fiellin, Lynn E. | O’Connor, Patrick G. | Bedimo, Roger | Gibert, Cynthia | Marconi, Vincent C. | Rimland, David | Rodriguez-Barradas, Maria C. | Simberkoff, Michael S. | Justice, Amy C. | Bryant, Kendall J. | Fiellin, David A. | Giles, Emma L. | Coulton, Simon | Deluca, Paolo | Drummond, Colin | Howel, Denise | McColl, Elaine | McGovern, Ruth | Scott, Stephanie | Stamp, Elaine | Sumnall, Harry | Vale, Luke | Alabani, Viviana | Atkinson, Amanda | Boniface, Sadie | Frankham, Jo | Gilvarry, Eilish | Hendrie, Nadine | Howe, Nicola | McGeechan, Grant J. | Ramsey, Amy | Stanley, Grant | Clephane, Justine | Gardiner, David | Holmes, John | Martin, Neil | Shevills, Colin | Soutar, Melanie | Chi, Felicia W. | Weisner, Constance | Ross, Thekla B. | Mertens, Jennifer | Sterling, Stacy A. | Shorter, Gillian W. | Heather, Nick | Bray, Jeremy | Cohen, Hildie A. | McPherson, Tracy L. | Adam, Cyrille | López-Pelayo, Hugo | Gual, Antoni | Segura-Garcia, Lidia | Colom, Joan | Ornelas, India J. | Doyle, Suzanne | Donovan, Dennis | Duran, Bonnie | Torres, Vanessa | Gaume, Jacques | Grazioli, Véronique | Fortini, Cristiana | Paroz, Sophie | Bertholet, Nicolas | Daeppen, Jean-Bernard | Satterfield, Jason M. | Gregorich, Steven | Alvarado, Nicholas J. | Muñoz, Ricardo | Kulieva, Gozel | Vijayaraghavan, Maya | Adam, Angéline | Cunningham, John A. | Díaz, Estela | Palacio-Vieira, Jorge | Godinho, Alexandra | Kushir, Vladyslav | O’Brien, Kimberly H. M. | Aguinaldo, Laika D. | Sellers, Christina M. | Spirito, Anthony | Chang, Grace | Blake-Lamb, Tiffany | LaFave, Lea R. Ayers | Thies, Kathleen M. | Pepin, Amy L. | Sprangers, Kara E. | Bradley, Martha | Jorgensen, Shasta | Catano, Nico A. | Murray, Adelaide R. | Schachter, Deborah | Andersen, Ronald M. | Rey, Guillermina Natera | Vahidi, Mani | Rico, Melvin W. | Baumeister, Sebastian E. | Johansson, Magnus | Sinadinovic, Christina | Hermansson, Ulric | Andreasson, Sven | O’Grady, Megan A. | Kapoor, Sandeep | Akkari, Cherine | Bernal, Camila | Pappacena, Kristen | Morley, Jeanne | Auerbach, Mark | Neighbors, Charles J. | Kwon, Nancy | Conigliaro, Joseph | Morgenstern, Jon | Magill, Molly | Apodaca, Timothy R. | Borsari, Brian | Hoadley, Ariel | Scott Tonigan, J. | Moyers, Theresa | Fitzgerald, Niamh M. | Schölin, Lisa | Barticevic, Nicolas | Zuzulich, Soledad | Poblete, Fernando | Norambuena, Pablo | Sacco, Paul | Ting, Laura | Beaulieu, Michele | Wallace, Paul George | Andrews, Matthew | Daley, Kate | Shenker, Don | Gallagher, Louise | Watson, Rod | Weaver, Tim | Bruguera, Pol | Oliveras, Clara | Gavotti, Carolina | Barrio, Pablo | Braddick, Fleur | Miquel, Laia | Suárez, Montse | Bruguera, Carla | Brown, Richard L. | Capell, Julie Whelan | Paul Moberg, D. | Maslowsky, Julie | Saunders, Laura A. | McCormack, Ryan P. | Scheidell, Joy | Gonzalez, Mirelis | Bauroth, Sabrina | Liu, Weiwei | Lindsay, Dawn L. | Lincoln, Piper | Hagle, Holly | Wallhed Finn, Sara | Hammarberg, Anders | Andréasson, Sven | King, Sarah E. | Vargo, Rachael | Kameg, Brayden N. | Acquavita, Shauna P. | Van Loon, Ruth Anne | Smith, Rachel | Brehm, Bonnie J. | Diers, Tiffiny | Kim, Karissa | Barker, Andrea | Jones, Ashley L. | Skinner, Asheley C. | Hinman, Agatha | Svikis, Dace S. | Thacker, Casey L. | Resnicow, Ken | Beatty, Jessica R. | Janisse, James | Puder, Karoline | Bakshi, Ann-Sofie | Milward, Joanna M. | Kimergard, Andreas | Garnett, Claire V. | Crane, David | Brown, Jamie | West, Robert | Michie, Susan | Rosendahl, Ingvar | Andersson, Claes | Gajecki, Mikael | Blankers, Matthijs | Donoghue, Kim | Lynch, Ellen | Maconochie, Ian | Phillips, Ceri | Pockett, Rhys | Phillips, Tom | Patton, R. | Russell, Ian | Strang, John | Stewart, Maureen T. | Quinn, Amity E. | Brolin, Mary | Evans, Brooke | Horgan, Constance M. | Liu, Junqing | McCree, Fern | Kanovsky, Doug | Oberlander, Tyler | Zhang, Huan | Hamlin, Ben | Saunders, Robert | Barton, Mary B. | Scholle, Sarah H. | Santora, Patricia | Bhatt, Chirag | Ahmed, Kazi | Hodgkin, Dominic | Gao, Wenwu | Merrick, Elizabeth L. | Drebing, Charles E. | Larson, Mary Jo | Sharma, Monica | Petry, Nancy M. | Saitz, Richard | Weisner, Constance M. | Young-Wolff, Kelly C. | Lu, Wendy Y. | Blosnich, John R. | Lehavot, Keren | Glass, Joseph E. | Williams, Emily C. | Bensley, Kara M. | Chan, Gary | Dombrowski, Julie | Fortney, John | Rubinsky, Anna D. | Lapham, Gwen T. | Forray, Ariadna | Olmstead, Todd A. | Gilstad-Hayden, Kathryn | Kershaw, Trace | Dillon, Pamela | Weaver, Michael F. | Grekin, Emily R. | Ellis, Jennifer D. | McGoron, Lucy | McGoron, Lucy
doi:10.1186/s13722-017-0087-8
PMCID: PMC5606215
2.  Private Health Plans’ Contracts with Managed Behavioral Healthcare Organizations 
Contracts between health plans and managed behavioral health care organizations (MBHOs) influence access and quality of behavioral health care. This report presents information on performance requirements, information sharing, and financial risk from a nationally representative survey of private health plans. Most contracts include geographic access to providers (93.3%) and NCQA’s performance standards (84.2%). Health plans and MBHOs share data (99.0%), generally by the MBHO sending information to the health plan (96.3%). About a quarter of contracts impose financial penalties (23.0%), but few include incentives related to performance standards (<1.0%). Contract terms can shape the provision of behavioral health services in response to changes such as parity legislation or health reform. If current trends continue towards increases in value-based purchasing in the privately financed behavioral health sector, the focus on quality in contracts between health plans and MBHOs will be critical to understand.
doi:10.1007/s11414-015-9474-7
PMCID: PMC4754164  PMID: 26276421
3.  How Health Plans Promote Health IT to Improve Behavioral Health Care 
Objectives
Given the large numbers of providers and enrollees with which they interact, health plans can encourage the use of health information technology (IT) to advance behavioral health care. The manner and extent to which commercial health plans promote health IT to improve behavioral health care is unknown. This study aims to address that gap.
Study Design
Cross-sectional study.
Methods
Data are from a nationally representative survey of commercial health plans regarding administrative and clinical dimensions of behavioral health services in 2010. Data are weighted to be representative of commercial managed care products in the United States (N=8,427; 88% response rate). Approaches within the domains of provider support, access to care, and assessment and treatment were investigated as examples of how health plans can promote health IT to improve behavioral health care delivery.
Results
Health plans were using health IT approaches in each domain. About a quarter of products offered financial support for electronic health records, but technical assistance was rare. Primary care providers could bill for email contact with patients for behavioral health in about a quarter of products. Few products offered member-provider email and none offered online appointment scheduling. However, online referral systems and online provider directories were common. Nearly all offered an online self-assessment tool; most offered online counseling and online personalized responses to questions or problems.
Conclusions
In 2010, commercial health plans encouraged the use of health IT strategies for behavioral health care. Health plans have an important role to play for increasing health IT as a tool for behavioral health care.
PMCID: PMC5629964  PMID: 27982663
4.  Access to Addiction Pharmacotherapy in Private Health Plans 
Background
An increasing number of medications are available to treat addictions. To understand access to addiction medications, it is essential to consider the role of private health plans. To contain medication expenditures, most U.S. health plans use cost-sharing and administrative controls, which may impact physicians' prescribing and patients' use of addiction medications. This study identified health plan approaches to manage access to and utilization of addiction medications (oral and injectable naltrexone, acamprosate, and buprenorphine).
Methods
Data are from a nationally representative survey of private health plans in 2010 (n=385 plans, 935 products; response rate 89%), compared to the same survey in 2003. The study assessed formulary inclusion, prior authorization, step therapy, overall restrictiveness, and if and how health plans encourage pharmacotherapy.
Results
Formulary exclusions were rare in 2010, with acamprosate excluded most often, by only 9% of products. Injectable naltrexone was covered by 96% of products. Prior authorization was common for injectable naltrexone (85%) and rare for acamprosate (3%). Step therapy policies were used only for injectable naltrexone (41%) and acamprosate (20%). Several medications were often on the most expensive tier. Changes since 2003 include fewer exclusions, yet increased use of other management approaches. Most health plans encourage use of addiction pharmacotherapy, and use a variety of methods to do so.
Conclusions
Management of addiction medications has increased over time but it is not ubiquitous. However, health plans now also include all medications on formularies and encourage providers to use them, indicating they value addiction pharmacotherapy as an evidence-based practice.
doi:10.1016/j.jsat.2016.03.001
PMCID: PMC4879589  PMID: 27211993
substance use disorders; pharmacotherapy; medication-assisted treatment; insurance; health plans; access
5.  Behavioral Health Services in the Changing Landscape of Private Health Plans 
Objective
Health plans play a key role in facilitating improvements in population health and may engage in activities that have an impact on access, cost, and quality of behavioral health care. Although behavioral health care is becoming more integrated with general medical care, its delivery system has unique aspects. The study examined how health plans deliver and manage behavioral health care in the context of the Affordable Care Act (ACA) and the 2008 Mental Health Parity and Addiction Equity Act (MHPAEA). This is a critical time to examine how health plans manage behavioral health care.
Methods
A nationally representative survey of private health plans (weighted N=8,431 products; 89% response rate) was conducted in 2010 during the first year of MHPAEA, when plans were subject to the law but before final regulations, and just before the ACA went into effect. The survey addressed behavioral health coverage, cost-sharing, contracting arrangements, medical home innovations, support for technology, and financial incentives to improve behavioral health care.
Results
Coverage for inpatient and outpatient behavioral health services was stable between 2003 and 2010. In 2010, health plans were more likely than in 2003 to manage behavioral health care through internal arrangements and to contract for other services. Medical home initiatives were common and almost always included behavioral health, but financial incentives did not. Some plans facilitated providers’ use of technology to improve care delivery, but this was not the norm.
Conclusions
Health plans are key to mainstreaming and supporting delivery of high-quality behavioral health services. Since 2003, plans have made changes to support delivery of behavioral health services in the context of a rapidly changing environment.
doi:10.1176/appi.ps.201500235
PMCID: PMC4889503  PMID: 26876663
6.  Accessing Specialty Behavioral Health Treatment in Private Health Plans 
Connecting people to mental health and substance abuse services is critical, given the extent of unmet need. The way health plans structure access to care can play a role. This study examined treatment entry procedures for specialty behavioral health care in private health plans, and their relationship with behavioral health contracting arrangements, focusing primarily on initial entry into outpatient treatment. The data source was a nationally representative health plan survey on behavioral health services in 2003 (N= 368 plans with 767 managed care products; 83% response rate). Most health plan products initially authorized six or more outpatient visits if authorization was required, did not routinely conduct telephonic clinical assessment, had standards for timely access, and monitored wait time. Products with carve-outs differed on several treatment entry dimensions. Findings suggest that health plans focus on timely access and typically do not heavily manage initial entry into outpatient treatment.
doi:10.1007/s11414-008-9161-z
PMCID: PMC4364135  PMID: 19104944
mental health; substance abuse; managed care; access; health plans
7.  ENGAGEMENT IN OUTPATIENT SUBSTANCE ABUSE TREATMENT AND EMPLOYMENT OUTCOMES 
The journal of behavioral health services & research  2014;41(1):10.1007/s11414-013-9334-2.
This study, a collaboration between an academic research center and Washington State’s health, employment and correction departments, investigates the extent to which treatment engagement, a widely adopted performance measure, is associated with employment, an important outcome for individuals receiving treatment for substance use disorders. Two-stage Heckman probit regressions were conducted using 2008 administrative data for 7,570 adults receiving publicly-funded treatment. The first stage predicted employment in the year following the first treatment visit and three separate second stages models predicted number of quarters employed, wages, and hours worked. Engagement as a main effect was not significant for any of the employment outcomes. However, for clients with prior criminal justice involvement, engagement was associated with both employment and higher wages following treatment. Clients with criminal justice involvement face greater challenge regarding employment, so the identification of any actionable step which increases the likelihood of employment or wages is an important result.
doi:10.1007/s11414-013-9334-2
PMCID: PMC3796147  PMID: 23686216
engagement; employment; substance use disorders; criminal justice; performance measures
8.  Health Plans’ Early Response to Federal Parity Legislation for Mental Health and Addiction Services 
Objective
In 2008 the federal Mental Health Parity and Addiction Equity Act (MHPAEA) passed, prohibiting U.S. health plans from subjecting mental health and substance use disorder (behavioral health) coverage to more restrictive limitations than those applied to general medical care. This require d some health plans to make changes in coverage and management of services. The aim of this study was to examine private health plans’ early responses to MHPAEA (after its 2010 implementation), in terms of both the intended and unintended effects.
Methods
Data were from a nationally representative survey of commercial health plans regarding the 2010 benefit year and the preparity 2009 benefit year (weighted N=8,431 products; 89% response rate).
Results
Annual limits specific to behavioral health care were virtually eliminated between 2009 and 2010. Prevalence of behavioral health coverage was unchanged, and copayments for both behavioral and general medical services increased slightly. Prior authorization requirements for specialty medical and behavioral health outpatient services continued to decline, and the proportion of products reporting strict continuing review requirements increased slightly. Contrary to expectations, plans did not make significant changes in contracting arrangements for behavioral health services, and 80% reported an increase in size of their behavioral health provider network.
Conclusions
The law had the intended effect of eliminating quantitative limitations that applied only to behavioral health care without unintended consequences such as eliminating behavioral health coverage. Plan decisions may also reflect other factors, including anticipation of the 2010 regulations and a continuation of trends away from requiring prior authorization.
doi:10.1176/appi.ps.201400575
PMCID: PMC4738051  PMID: 26369886
9.  Combat-acquired traumatic brain injury, posttraumatic stress disorder, and their relative associations with postdeployment binge drinking 
Objective
To examine whether experiencing a traumatic brain injury (TBI) on a recent combat deployment was associated with postdeployment binge drinking, independent of posttraumatic stress disorder (PTSD).
Methods
Using the 2008 Department of Defense Survey of Health Related Behaviors among Active Duty Military Personnel, an anonymous survey completed by 28,546 personnel, the study sample included 6,824 personnel who had a combat deployment in the past year. Path analysis was used to examine whether PTSD accounted for the total association between TBI and binge drinking.
Main Measures
The dependent variable, binge drinking days, was an ordinal measure capturing the number of times personnel drank 5+ drinks on one occasion (4+ for women) in the past month. TBI-level captured the severity of TBI after a combat injury event exposure: TBI-AC (altered consciousness only), TBI-LOC≤20 (loss of consciousness up to 20 minutes), and TBI-LOC>20 (loss of consciousness greater than 20 minutes). APTSD positive screen relied on the standard diagnostic cutoff of 50+ on the PCL-C.
Results
The final path model found that while the direct effect of TBI (0.097) on binge drinking was smaller than that of PTSD (0.156), both were significant. Almost 70% of the total effect of TBI on binge drinking was from the direct effect; only 30% represented the indirect effect through PTSD.
Conclusion
Further research is needed to replicate these findings and to understand the underlying mechanisms that explain the relationship between TBI and increased postdeployment drinking.
doi:10.1097/HTR.0000000000000082
PMCID: PMC4395509  PMID: 25310293
traumatic brain injury; combat; military personnel; alcohol drinking; posttraumatic stress disorder; path analysis
10.  Older Adults’ Inpatient and Emergency Department Utilization For Ambulatory-Care-Sensitive Conditions: Relationship with Alcohol Consumption 
Journal of aging and health  2010;23(1):86-111.
Objectives
This study examined the relationship between drinking that exceeds guideline-recommended limits and acute-care utilization for ambulatory-care-sensitive conditions (ACSCs) by older Medicare beneficiaries.
Methods
This secondary data analysis utilized the 2001–2006 Medicare Current Beneficiary Survey (unweighted n=5,570 community dwelling, past-year drinkers, 65 years and older). Self-reported alcohol consumption (categorized as within-guidelines, exceeding monthly but not daily limits, or heavy episodic) and covariates were used to predict ACSC hospitalization, emergency department visit not resulting in admission, and emergency department visit that did result in admission.
Results
Heavy episodic drinking was significantly associated with higher likelihood of an ACSC emergency department visit not resulting in admission (adjusted odds ratio 1.91, 95% CI 1.11 – 3.30; p<.05). Drinking pattern was not significant for other ACSC measures.
Discussion
Results partially support the hypothesis that excessive drinking may be related to ACSC acute-care utilization among older adults, suggesting increased risk of lower-quality outpatient care.
doi:10.1177/0898264310383156
PMCID: PMC3021178  PMID: 20935248
older adults; alcohol; ambulatory-care-sensitive conditions; health care utilization; quality of care
11.  EAP Service Use in a Managed Behavioral Health Care Organization: From the Employee Perspective 
SUMMARY
Contemporary employee assistance program (EAP) services are typically provided in broad-brush programs delivered by large external vendors in a network model. Yet research has not kept pace with EAP evolution, including in terms of how EAP clients themselves view services. We surveyed a random sample of EAP service users from a national provider (361 respondents). About one-third of respondents reported getting help for workplace issues. Most learned about the EAP through employer communications such as the company website. The large majority reported that the EAP helped them “a lot” or “some,” suggesting they valued this benefit.
doi:10.1080/15555240.2011.573751
PMCID: PMC3182492  PMID: 21966281
Employee assistance programs; consumers; experience of care; utilization; workplace; substance abuse; mental health
12.  Changes in How Health Plans Provide Behavioral Health Services 
Health plans appear to be moving towards 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.
doi:10.1007/s11414-007-9084-0
PMCID: PMC2982768  PMID: 17874188
Behavioral health; managed care; health plans; mental health; substance abuse
13.  Management of Newer Antidepressant Medications in U.S. Commercial Health Plans 
Background
Private health insurance plays a large role in the US health system, including for many individuals with depression. Private insurers have been actively trying to influence pharmaceutical utilization and costs, particularly for newer and costlier medications. The approaches that insurers use may have important effects on patients’ access to antidepressant medications.
Aims of the Study
To report which approaches (e.g., tiered copayments, prior authorization, and step therapy) commercial health plans are employing to manage newer antidepressant medications, and how the use of these approaches has changed since 2003.
Methods
Data are from a nationally representative survey of commercial health plans in 60 market areas regarding alcohol, drug abuse and mental health services in 2010. Responses were obtained from 389 plans (89% response rate), reporting on 925 insurance products. For each of six branded antidepressant medications, respondents were asked whether the plan covered the medication and if so, on what copayment tier, and whether it was subject to prior authorization or step therapy. Measures of management approach were constructed for each medication and for the group of medications. Bivariate and multivariate analyses were used to test for association of the management approach with various health plan characteristics.
Results
Less than 1% of health plan products excluded any of the six antidepressants studied. Medications were more likely to be subjected to restrictions if they were newer, more expensive or were reformulations. 55% of products used placement on a high cost-sharing tier (3 or 4) as their only form of restriction for newer branded antidepressants. This proportion was lower than in 2003, when 71% of products took this approach. In addition, only 2% of products left all the newer branded medications unrestricted, down from 25% in 2003. Multivariate analysis indicated that preferred provider organizations were more likely than other product types to use tier 3 or 4 placement.
Discussion
We find that U.S. health plans are using a variety of strategies to manage cost and utilization of newer branded antidepressant medications. Plans appear to be finding that approaches other than exclusion are adequate to meet their cost-management goals for newer branded antidepressants, although they have increased their use of administrative restrictions since 2003. Limitations include lack of information about how administrative restrictions were applied in practice, information on only six medications, and some potential for endogeneity bias in the regression analyses.
Conclusion
This study has documented substantial use of various restrictions on access to newer branded antidepressants in U.S. commercial health plans. Most of these medications had generic equivalents that offered at least some substitutability, reducing access concerns. At the same time, it is worth noting that high copayments and administrative requirements can nonetheless be burdensome for some patients.
Implications for Health Policy
Health plans’ pharmacy management approaches may concern policymakers less than in the early 2000s, due to the lesser distinctiveness of today’s branded medications. This may change depending on future drug introductions.
Implications for Further Research
Future research should examine the impact of plans’ pharmacy management approaches, using patient-level data.
PMCID: PMC4812668  PMID: 26729008
14.  Availability of Addiction Medications in Private Health Plans 
Health plans have implemented cost-sharing and administrative controls to constrain escalating prescription expenditures. These policies may impact physicians’ prescribing and patients’ use of these medications. Important clinical advances in the pharmacologic treatment of addiction highlight the need to examine how pharmacy benefits consider medications to treat substance dependence. The extent of restrictions influencing availability of these medications to consumers is unknown. We use nationally representative survey data to examine the extent and stringency of private health plans’ management of naltrexone and disulfiram for alcohol dependence, and buprenorphine for opiate dependence. Thirty-one percent of insurance products excluded buprenorphine from formularies, while 55% placed it on the highest cost-sharing tier. Generic naltrexone is the only substance dependence medication that is both rarely excluded from formularies and usually placed on a lower cost-sharing tier. These findings demonstrate that pharmacy benefits have an impact on access to medications to treat substance abuse.
doi:10.1016/j.jsat.2007.02.004
PMCID: PMC2347353  PMID: 17499959
pharmacotherapy; cost-sharing; pharmacy benefits; formulary; substance abuse
15.  Does Type of Gatekeeping Model Affect Access to Outpatient Specialty Mental Health Services? 
Health Services Research  2007;42(1 Pt 1):104-123.
Objective
To measure how a change in gatekeeping model affects utilization of specialty mental health services.
Data Sources/Study Setting
Secondary data from health insurance claims for services during 1996–1999. The setting is a managed care organization that changed gatekeeping model in one of its divisions, from in-person evaluation to the use of a call-center.
Study Design
We evaluate the impact of the change in gatekeeping model by comparing utilization during the 2 years before and 2 years after the change, both in the affected division and in another division where gatekeeping model did not change. The design is thus a controlled quasi-experimental one. Subjects were not randomized. Key dependent variables are whether each individual had any specialty mental health visits in a year; the number of visits; and the proportion of users exceeding eight visits in a year. Key explanatory variables include demographic variables and indicators for patient diagnoses and their intervention status (time-period, study group).
Data Collection/Extraction Methods
Claims data were aggregated to create analytic files with one record per member per year, with variables reporting demographic characteristics and mental health service use.
Principal Findings
After controlling for secular trends at the other division, the division which changed gatekeeping model eventually experienced an increase in the proportion of enrollees receiving specialty mental health treatment, of 0.5 percentage point. Similarly, there was an increase of about 0.6 annual visits per user, concentrated at the low end of the distribution. These changes occurred only in the second year after the gatekeeping changes.
Conclusions
The results of this study suggest that the gatekeeping changes did lead to increases in utilization of mental health care, as hypothesized. At the same time, the magnitude of the increase in access and mean number of visits that we found was relatively modest. This suggests that while the change from face-to-face specialty gatekeeping to call-center intake does increase utilization, it is unlikely to overwhelm a system with new demand or create huge cost increases.
doi:10.1111/j.1475-6773.2006.00609.x
PMCID: PMC1955246  PMID: 17355584
Mental health; gatekeeping; utilization management
16.  Management of Newer Medications for Attention-Deficit Hyperactivity Disorder In Commercial Health Plans 
Clinical therapeutics  2014;36(12):2034-2046.
Purpose
In the US, many individuals with attention deficit hyperactivity disorder (ADHD) pay for their medications using private health insurance coverage. As in other drug classes, private insurers are actively seeking to influence utilization and costs, particularly for newer and costlier medications. The approaches that insurers use may have important effects on patients’ access to medications. This paper examines approaches (e.g., copayments, prior authorization, and step therapy) that commercial health plans are employing to manage newer medications used to treat ADHD and changes in approaches since 2003.
Methods
Data are from a nationally representative survey of commercial health plans in 60 market areas regarding alcohol, drug abuse and mental health services in 2010. Responses were obtained from 389 plans (89% response rate), reporting on 925 insurance products. For each of six branded ADHD medications, respondents were asked whether the plan covered the medication and if so, on what copayment tier each medication was placed, and whether it was subject to prior authorization or step therapy. Measures of management approach were constructed for each medication and for the group of medications. Bivariate and multivariate analyses were used to test for association of the management approach with various health plan characteristics.
Findings
There was considerable variation across these 6 medications in how tightly they were managed by health plans, with newer medications being subject to more stringent management. The proportion of insurance products relying solely on copay tiering to manage novel ADHD medications appears to have decreased since 2003. Less than half of insurance products (43%) managed these 6 medications solely by use of Tier 3/4 placement, and most of the remainder (48%) used other restrictions (with or without Tier 3/4 placement). The average insurance product restricted access to at least 3 of the 6 brand-only medications examined, whether through copayment tier placement or other approaches. More ADHD medications were left unrestricted in HMO products than in PPO ones; products with internal or hybrid-internal contracts for behavioral health; those not contracting with pharmacy benefits managers; and those with for-profit ownership.
Implications
Many plans have supplemented copayment tiering with other approaches such as prior authorization and step therapy to influence utilization and decrease costs. It may be that plans have found copayments to be less effective in redirecting utilization in this medication class. The impact on clinical outcomes was not examined in this study but should be prioritized using other data sources.
doi:10.1016/j.clinthera.2014.09.019
PMCID: PMC4282778  PMID: 25450473
Attention deficit hyperactivity disorder; formularies; prior authorization; copayments; step therapy; ADHD medications
17.  A Performance Measure for Continuity of Care After Detoxification: Relationship With Outcomes 
Administrative data from five states were used to examine whether continuity of specialty substance abuse treatment after detoxification predicts outcomes. We examined the influence of a 14-day continuity of care process measure on readmissions. Across multiple states, there was support that clients who received treatment for substance use disorders within 14-days after discharge from detoxification were less likely to be readmitted to detoxification. This was particularly true for reducing readmissions to another detoxification that was not followed with treatment and when continuity of care was in residential treatment. Continuity of care in outpatient treatment was related to a reduction in readmissions in some states, but not as often as when continuity of care occurred in residential treatment. A performance measure for continuity of care after detoxification is a useful tool to help providers monitor quality of care delivered and to alert them when improvement is needed.
doi:10.1016/j.jsat.2014.04.002
PMCID: PMC4096006  PMID: 24912862
continuity of care; detoxification; performance measures; readmission; administrative data
18.  Health Plans' Disease Management Programs: Extending across the Medical and Behavioral Health Spectrum? 
While the disease management industry has expanded rapidly, there is little nationally representative data regarding medical and behavioral health disease management programs at the health plan level. National estimates from a survey of private health plans indicate that 90% of health plan products offered disease management for general medical conditions such as diabetes, but only 37% had depression programs. The frequency of specific depression disease management activities varied widely. Program adoption was significantly related to product type and behavioral health contracting. In health plans, disease management has penetrated more slowly into behavioral health, and depression program characteristics are highly variable.
doi:10.1097/01.JAC.0000336553.69707.e5
PMCID: PMC4405107  PMID: 18806594
disease management; depression; managed care; health plans
19.  Criminal Justice Outcomes after Engagement in Outpatient Substance Abuse Treatment 
The relationship between engagement in outpatient treatment facilities in the public sector and subsequent arrest is examined for clients in Connecticut, New York, Oklahoma and Washington. Engagement is defined as receiving another treatment service within 14 days of beginning a new episode of specialty treatment and at least two additional services within the next 30 days. Data are from 2008 and survival analysis modeling is used. Survival analyses express the effects of model covariates in terms of “hazard ratios,” which reflect a change in the likelihood of outcome because of the covariate. Engaged clients had a significantly lower hazard of any arrest than non-engaged in all four states. In NY and OK, engaged clients also had a lower hazard of arrest for substance-related crimes. In CT, NY, and OK engaged clients had a lower hazard of arrest for violent crime. Clients in facilities with higher engagement rates had a lower hazard of any arrest in NY and OK. Engaging clients in outpatient treatment is a promising approach to decrease their subsequent criminal justice involvement.
doi:10.1016/j.jsat.2013.10.005
PMCID: PMC3947052  PMID: 24238717
21.  Drinking Patterns of Older Adults with Chronic Medical Conditions 
Journal of General Internal Medicine  2013;28(10):1326-1332.
ABSTRACT
BACKGROUND
Understanding alcohol consumption patterns of older adults with chronic illness is important given the aging baby boomer generation, the increase in prevalence of chronic conditions and associated medication use, and the potential consequences of excessive drinking in this population.
OBJECTIVES
To estimate the prevalence of alcohol consumption patterns, including at-risk drinking, in older adults with at least one of seven common chronic conditions.
DESIGN/METHODS
This descriptive study used the nationally representative 2005 Medicare Current Beneficiary Survey linked with Medicare claims. The sample included community-dwelling, fee-for-service beneficiaries 65 years and older with one or more of seven chronic conditions (Alzheimer’s disease and other senile dementia, chronic obstructive pulmonary disease, depression, diabetes, heart failure, hypertension, and stroke; n = 7,422). Based on self-reported alcohol consumption, individuals were categorized as nondrinkers, within-guidelines drinkers, or at-risk drinkers (exceeds guidelines).
RESULTS
Overall, 30.9 % (CI 28.0–34.1 %) of older adults with at least one of seven chronic conditions reported alcohol consumption in a typical month in the past year, and 6.9 % (CI 6.0–7.8 %) reported at-risk drinking. Older adults with higher chronic disease burdens were less likely to report alcohol consumption and at-risk drinking.
CONCLUSIONS
Nearly one-third of older adults with selected chronic illnesses report drinking alcohol and almost 7 % drink in excess of National Institute on Alcohol Abuse and Alcoholism (NIAAA) guidelines. It is important for physicians and patients to discuss alcohol consumption as a component of chronic illness management. In cases of at-risk drinking, providers have an opportunity to provide brief intervention or to offer referrals if needed.
doi:10.1007/s11606-013-2409-1
PMCID: PMC3785666  PMID: 23609178
at-risk drinking; alcohol consumption; Medicare beneficiaries; chronic conditions; older adults
22.  Establishing the Feasibility of Measuring Performance in Use of Addiction Pharmacotherapy 
This paper presents the rationale and feasibility of standardized performance measures for use of pharmacotherapy in the treatment of substance use disorders (SUD), an evidence-based practice and critical component of treatment that is often underused. These measures have been developed and specified by the Washington Circle, to measure treatment of alcohol and opioid dependence with FDA-approved prescription medications for use in office-based general health and addiction specialty care. Measures were pilot tested in private health plans, the Veterans Health Administration (VHA), and Medicaid. Testing revealed that use of standardized measures using administrative data for overall use and initiation of SUD pharmacotherapy is feasible and practical. Prevalence of diagnoses and use of pharmacotherapy varies widely across health systems. Pharmacotherapy is generally used in a limited portion of those for whom it might be indicated. An important methodological point is that results are sensitive to specifications, so that standardization is critical to measuring performance across systems.
doi:10.1016/j.jsat.2013.01.004
PMCID: PMC3954716  PMID: 23490233
performance measurement; pharmacotherapy; addiction medication; Veterans Health; Medicaid
23.  Performance Contracting and Quality Improvement in Outpatient Treatment: Effects on Waiting Time and Length of Stay 
We evaluate effects of a performance contract (PC) implemented in Delaware in 2001 and participation in quality improvement (QI) programs on waiting time for treatment and length of stay (LOS) using client treatment episode level data from Delaware (n = 12,368) and Maryland (n = 147,151) for 1998 – 2006. Results of difference-in-difference analyses indicate waiting time declined 13 days following the PC, after controlling for client characteristics and historical trends. Participation in the PC and a formal QI program was associated with a decrease of 20 days. LOS increased 22 days under the PC and 24 days under the PC and QI programs, after controlling for client characteristics. The PC and QI program were associated with improvements in LOS and waiting time, although we cannot determine which aspects of the programs (incentives, training, monitoring) resulted in these changes.
doi:10.1016/j.jsat.2012.02.001
PMCID: PMC3584559  PMID: 22445031
Performance contract; pay-for-performance; financial incentives; quality improvement; substance abuse treatment
24.  Racial/Ethnic Differences in Substance Abuse Treatment Initiation and Engagement 
This study examined variations by race/ethnicity in initiation and engagement, two performance measures of treatment for substance use disorders, which focus on the timely receipt of services during the early stage of treatment. Administrative data from the Oklahoma Department of Mental Health and Substance Abuse Services were linked with facility-level information from the National Survey of Substance Abuse Treatment Services. We found that Black clients were less likely to initiate treatment, but we found no differences in treatment engagement by race/ethnicity. Most client and facility characteristics’ association with initiation or engagement did not differ across racial/ethnic groups. Increased attention is needed to understand what may contribute to the differences found and how to address them. This study also offers an approach that state agencies may implement for monitoring treatment quality and examining racial/ethnic disparities in substance abuse treatment services.
doi:10.1080/15332640.2012.652516
PMCID: PMC3699873  PMID: 22381120
Substance abuse treatment; race/ethnicity; performance measures; treatment initiation; treatment engagement
25.  Customization in Prescribing for Bipolar Disorder 
Health Economics  2011;21(6):653-668.
For many disorders, patient heterogeneity requires physicians to customize their treatment to each patient’s needs. We test for the existence of customization in physicians’ prescribing for bipolar disorder, using data from a naturalistic clinical effectiveness trial of bipolar disorder treatment (STEP-BD), which did not constrain physician prescribing. Multinomial logit is used to model the physician’s choice among five combinations of drug classes. We find that our observed measure of the patient’s clinical status played only a limited role in the choice among drug class combinations, even for conditions such as mania that are expected to affect class choice. However, treatment of a patient with given characteristics differed widely depending on which physician was seen. The explanatory power of the model was low. There was variation within each physician’s prescribing, but the results do not suggest a high degree of customization in physicians’ prescribing, based on our measure of clinical status.
doi:10.1002/hec.1737
PMCID: PMC3164906  PMID: 21506194
Bipolar disorder; pharmaceuticals; prescribing decisions; personalization

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