Development of a New Screening Tool for Pediatric Septic Shock.

STUDY OBJECTIVE: Existing screening tools for sepsis in children are limited by suboptimal sensitivity. Our objective was to develop a new, more sensitive screening tool for pediatric septic shock by enhancing 2 aspects of the 4-point Liverpool quick Sequential Organ Failure Assessment (LqSOFA) tool. METHODS: We performed a secondary analysis of a cohort of children (1 month to 18 years) who presented to a pediatric emergency department (ED) with suspected infection over a 10-year period. Septic shock was defined as intravenous vasoactive infusion within 24-hours of arrival for children with suspected infection and intravenous antibiotics administered. We developed the 4-point quick Pediatric Septic Shock Screening Score (qPS4) by making 2 changes to the 4-point LqSOFA: (1) the pulse rate parameter was replaced with the recently derived Temperature and Age-adjusted Mean Shock Index and (2) standard respiratory rate cutoffs for tachypnea were replaced by cutoffs derived empirically from the study cohort. The other 2 LqSOFA criteria were unchanged (abnormal mentation and capillary refill ≥3 seconds). We defined a positive qPS4 as ≥2 criteria (consistent with LqSOFA). We used the training cohort from the parent study to derive cutoffs for respiratory rate and the validation cohort to compare the qPS4 with LqSOFA and qSOFA. RESULTS: Among the 47,231 encounters in the validation cohort from the parent study, with median age of 4.5 years, qPS4 had an area under the receiver operating characteristic curve for septic shock of 0.94 (95% confidence interval [CI] 0.92 to 0.96). qPS4 ≥2 had a sensitivity of 89.7% (95% CI 84.9% to 94.5%), and a specificity of 92.2% (95% CI 92.0% to 92.5%) for septic shock. In comparison, the LqSOFA achieved an area under the receiver operating characteristic curve of 0.86 (95% CI 0.82 to 0.89), a sensitivity of 56.1% (95% CI 48.3% to 63.9%), and a specificity of 96.8% (95% CI 96.6% to 96.9%). The median time from first positive qPS4 to initiation of an intravenous vasoactive infusion was 2.5 hours (IQR 0.9 to 6.1) compared to 0.7 hours (IQR 0.0 to 4.5) for LqSOFA. CONCLUSION: The qPS4, with 2 enhancements to the LqSOFA, demonstrated overall improved sensitivity and specificity for pediatric septic shock.

Acquisitions of behavioral health treatment facilities from 2010 to 2021.

Private equity (PE) and other for-profit ownership of behavioral health (mental health and substance use) treatment facilities have become increasingly prevalent, but data on these acquisitions are not readily available. In this study, we describe a novel database that contains information on the universe of behavioral health acquisitions that occurred between 2010 and 2021. We found that the frequency of behavioral health facilities involved in acquisitions increased substantially, from 32 facilities in 2010 to 1330 in 2021. The total number of facilities involved in acquisitions was 2806. Most of these facilities provided outpatient services only (N = 2073) and offered only mental health services (N = 1428). Private equity-backed acquisitions accounted for around 60% of all acquisition activity (N = 1678 facilities PE, N = 1128 facilities other for-profit). 25% of acquired facilities were located within 20 miles of one another (N = 561), 50% occurred within 80 miles (N = 1403), and 75% occurred within 319 miles (N = 2104). Future research should evaluate the effects of this consolidation on behavioral healthcare access, quality, spending, and patient outcomes.

Delays to Antibiotics in the Emergency Department and Risk of Mortality in Children With Sepsis.

Importance: Pediatric consensus guidelines recommend antibiotic administration within 1 hour for septic shock and within 3 hours for sepsis without shock. Limited studies exist identifying a specific time past which delays in antibiotic administration are associated with worse outcomes. Objective: To determine a time point for antibiotic administration that is associated with increased risk of mortality among pediatric patients with sepsis. Design, Setting, and Participants: This retrospective cohort study used data from 51 US children's hospitals in the Improving Pediatric Sepsis Outcomes collaborative. Participants included patients aged 29 days to less than 18 years with sepsis recognized within 1 hour of emergency department arrival, from January 1, 2017, through December 31, 2021. Piecewise regression was used to identify the inflection point for sepsis-attributable 3-day mortality, and logistic regression was used to evaluate odds of sepsis-attributable mortality after adjustment for potential confounders. Data analysis was performed from March 2022 to February 2024. Exposure: The number of minutes from emergency department arrival to antibiotic administration. Main Outcomes and Measures: The primary outcome was sepsis-attributable 3-day mortality. Sepsis-attributable 30-day mortality was a secondary outcome. Results: A total of 19 515 cases (median [IQR] age, 6 [2-12] years) were included. The median (IQR) time to antibiotic administration was 69 (47-116) minutes. The estimated time to antibiotic administration at which 3-day sepsis-attributable mortality increased was 330 minutes. Patients who received an antibiotic in less than 330 minutes (19 164 patients) had sepsis-attributable 3-day mortality of 0.5% (93 patients) and 30-day mortality of 0.9% (163 patients). Patients who received antibiotics at 330 minutes or later (351 patients) had 3-day sepsis-attributable mortality of 1.2% (4 patients), 30-day mortality of 2.0% (7 patients), and increased adjusted odds of mortality at both 3 days (odds ratio, 3.44; 95% CI, 1.20-9.93; P = .02) and 30 days (odds ratio, 3.63; 95% CI, 1.59-8.30; P = .002) compared with those who received antibiotics within 330 minutes. Conclusions and Relevance: In this cohort of pediatric patients with sepsis, 3-day and 30-day sepsis-attributable mortality increased with delays in antibiotic administration 330 minutes or longer from emergency department arrival. These findings are consistent with the literature demonstrating increased pediatric sepsis mortality associated with antibiotic administration delay. To guide the balance of appropriate resource allocation with time for adequate diagnostic evaluation, further research is needed into whether there are subpopulations, such as those with shock or bacteremia, that may benefit from earlier antibiotics.

Licensure Policies May Help States Ensure Access To Opioid Use Disorder Medication In Specialty Addiction Treatment.

Despite the devastating toll of the overdose crisis in the United States, many addiction treatment programs do not offer medications for opioid use disorder (MOUD). Several states have incorporated MOUD requirements into their standards for treatment program licensure. This study examined policy officials' and treatment providers' perspectives on the implementation of these policies. During 2020-22, we conducted thirty-one semistructured interviews with forty policy officials and treatment providers in nine states identified through a legal analysis. Of these states, three states required treatment organizations to offer MOUD, and two prohibited organizations from denying admission to people receiving MOUD. Qualitative findings revealed that licensure policies were part of a broader effort to transition the specialty treatment system to a model of care more consistent with medical evidence; states perceived tension between raising quality standards and maintaining adequate treatment capacity; aligning other state policies with MOUD access goals facilitated implementation of the licensure requirement; and measuring compliance was challenging. Licensure may offer states an opportunity to take a more active role in ensuring access to effective treatment.

US payment policy for medications to treat opioid use disorder: landscape and opportunities.

Offering patients medications for opioid use disorder (MOUD) is the standard of care for opioid use disorder (OUD), but an estimated 75%-90% of people with OUD who could benefit from MOUD do not receive medication. Payment policy, defined as public and private payers' approaches to covering and reimbursing providers for MOUD, is 1 contributor to this treatment gap. We conducted a policy analysis and qualitative interviews (n = 21) and surveys (n = 31) with US MOUD payment policy experts to characterize MOUD insurance coverage across major categories of US insurers and identify opportunities for reform and innovation. Traditional Medicare, Medicare Advantage, and Medicaid all provide coverage for at least 1 formulation of buprenorphine, naltrexone, and methadone for OUD. Private insurance coverage varies by carrier and by plan, with methadone most likely to be excluded. The experts interviewed cautioned against rigid reimbursement models that force patients into one-size-fits-all care and endorsed future development and adoption of value-based MOUD payment models. More than 70% of experts surveyed reported that Medicare, Medicaid, and private insurers should increase payment for office- and opioid treatment program-based MOUD. Validation of MOUD performance metrics is needed to support future value-based initiatives.

Changes in Healthcare Spending Attributable to High Deductible Health Plan Offer Among Enrollees with Comorbid Substance Use Disorder and Cardiovascular Disease.

BACKGROUND: The rise in prevalence of high deductible health plans (HDHPs) in the United States may raise concerns for high-need, high-utilization populations such as those with comorbid chronic conditions. In this study, we examine changes in total and out-of-pocket (OOP) spending attributable to HDHPs for enrollees with comorbid substance use disorder (SUD) and cardiovascular disease (CVD). METHODS: We used de-identified administrative claims data from 2007 to 2017. SUD and CVD were defined using algorithms of ICD 9 and 10 codes and HEDIS guidelines. The main outcome measures of interest were spending measure for all non-SUD/CVD-related services, SUD-specific services, and CVD-specific services, for all services and medications specifically. We assessed both total and OOP spending. We used an intent-to-treat two-part model approach to model spending and computed the marginal effect of HDHP offer as both the dollar change and percent change in spending attributable to HDHP offer. RESULTS: Our sample included 33,684 enrollee-years and was predominantly white and male with a mean age of 53 years. The sample had high demonstrated substantial healthcare utilization with 94% using any non-SUD/CVD services, and 84% and 78% using SUD and CVD services, respectively. HDHP offer was associated with a 17.0% (95% CI = [0.07, 0.27] increase in OOP spending for all non-SUD/CVD services, a 21.1% (95% CI = [0.11, 0.31]) increase in OOP spending for all SUD-specific services, and a 13.1% (95% CI = [0.04, 0.23]) increase in OOP spending for all CVD-specific services. HDHP offer was also associated with a significant increase in OOP spending on non-SUD/CVD-specific medications and SUD-specific medications, but not CVD-specific medications. CONCLUSIONS: This study suggests that while HDHPs do not change overall levels of annual spending among enrollees with comorbid CVD and SUD, they may increase the financial burden of healthcare services by raising OOP costs, which could negatively impact this high-need and high-utilization population.

Administrative Frictions and the Mental Health Workforce.

This Viewpoint describes the administrative barriers experienced by mental health professionals and recommends strategies to address these barriers.

Navigating addiction treatment during COVID-19: policy insights from state health leaders.

To mitigate pandemic-related disruptions to addiction treatment, US federal and state governments made significant changes to policies regulating treatment delivery. State health agencies played a key role in implementing these policies, giving agency leaders a distinct vantage point on the feasibility and implications of post-pandemic policy sustainment. We interviewed 46 state health agency and other leaders responsible for implementing COVID-19 addiction treatment policies across 8 states with the highest COVID-19 death rate in their census region. Semi-structured interviews were conducted from April through October 2022. Transcripts were analyzed using summative content analysis to characterize policies that interviewees perceived would, if sustained, benefit addiction treatment delivery long-term. State policies were then characterized through legal database queries, internet searches, and analysis of existing policy databases. State leaders viewed multiple pandemic-era policies as useful for expanding addiction treatment access post-pandemic, including relaxing restrictions for telehealth, particularly for buprenorphine induction and audio-only treatment; take-home methadone allowances; mobile methadone clinics; and out-of-state licensing flexibilities. All states adopted at least 1 of these policies during the pandemic. Future research should evaluate these policies outside of the acute COVID-19 pandemic context.

Deductible imputation in administrative medical claims datasets.

OBJECTIVE: To validate imputation methods used to infer plan-level deductibles and determine which enrollees are in high-deductible health plans (HDHPs) in administrative claims datasets. DATA SOURCES AND STUDY SETTING: 2017 medical and pharmaceutical claims from OptumLabs Data Warehouse for US individuals <65 continuously enrolled in an employer-sponsored plan. Data include enrollee and plan characteristics, deductible spending, plan spending, and actual plan-level deductibles. STUDY DESIGN: We impute plan deductibles using four methods: (1) parametric prediction using individual-level spending; (2) parametric prediction with imputation and plan characteristics; (3) highest plan-specific mode of individual annual deductible spending; and (4) deductible spending at the 80th percentile among individuals meeting their deductible. We compare deductibles' levels and categories for imputed versus actual deductibles. DATA COLLECTION/EXTRACTION METHODS: Not applicable. PRINCIPAL FINDINGS: All methods had a positive predictive value (PPV) for determining high- versus low-deductible plans of ≥87%; negative predictive values (NPV) were lower. The method imputing plan-specific deductible spending modes was most accurate and least computationally intensive (PPV: 95%; NPV: 91%). This method also best correlated with actual deductible levels; 69% of imputed deductibles were within $250 of the true deductible. CONCLUSIONS: In the absence of plan structure data, imputing plan-specific modes of individual annual deductible spending best correlates with true deductibles and best predicts enrollees in HDHPs.

Job Flows Into and Out of Health Care Before and After the COVID-19 Pandemic.

Importance: Anecdotal evidence suggests that health care employers have faced increased difficulty recruiting and retaining staff in the wake of the COVID-19 pandemic. Empirical research is needed to understand the magnitude and persistence of these changes, and whether they have disproportionate implications for certain types of workers or regions of the country. Objective: To quantify the number of workers exiting from and entering into the health care workforce before and after the pandemic and to examine variations over time and across states and worker demographics. Design, Setting, and Participants: This cohort study used US Census Bureau state unemployment insurance data on job-to-job flows in the continental US to construct state-level quarterly exit and entry rates for the health care industry from January 2018 through December 2021 (Arkansas, Mississippi, and Tennessee were omitted due to missing data). An event study design was used to compute quarterly mean adjusted rates of job exit from and entry into the health care sector as defined by the North American Industry Classification System. Data were examined from January to June 2023. Exposure: The COVID-19 pandemic. Main Outcomes and Measures: The main outcomes were the mean adjusted health care worker exit and entry rates in each quarter by state and by worker demographics (age, gender, race and ethnicity, and education level). Results: In quarter 1 of 2020, there were approximately 18.8 million people (14.6 million females [77.6%]) working in the health care sector in our sample. The exit rate for health care workers increased at the onset of the pandemic, from a baseline quarterly mean of 5.9 percentage points in 2018 to 8.0 (95% CI, 7.7-8.3) percentage points in quarter 1 of 2020. Exit rates remained higher than baseline levels through quarter 4 of 2021, when the health care exit rate was 7.7 (95% CI, 7.4-7.9) percentage points higher than the 2018 baseline. In quarter 1 of 2020, the increase in health care worker exit rates was dominated by an increase in workers exiting to nonemployment (78% increase compared with baseline); in contrast, by quarter 4 of 2021, the exit rate was dominated by workers exiting to employment in non-health care sectors (38% increase compared with baseline). Entry rates into health care also increased in the postpandemic period, from 6.2 percentage points at baseline to 7.7 percentage points (95% CI, 7.4-7.9 percentage points) in the last quarter of 2021, suggesting increased turnover of health care staff. Compared with prepandemic job flows, the share of workers exiting health care after the pandemic who were female was disproportionately larger, and the shares of workers entering health care who were female or Black was disproportionately smaller. Conclusions and Relevance: Results of this cohort study suggest a substantial and persistent increase in health care workforce turnover after the pandemic, which may have long-lasting implications for workers' willingness to remain in health care jobs. Policymakers and health care organizations may need to act to prevent further losses of experienced staff.

Anxiety and Depression Symptoms After the Dobbs Abortion Decision.

Importance: In 2022, the US Supreme Court abolished the federal right to abortion in the Dobbs v Jackson Women's Health Organization decision. In 13 states, abortions were immediately banned via previously passed legislation, known as trigger laws. Objective: To estimate changes in anxiety and depression symptoms following the Dobbs decision among people residing in states with trigger laws compared with those without them. Design, Setting, and Participants: Using the nationally representative repeated cross-sectional Household Pulse Survey (December 2021-January 2023), difference-in-differences models were estimated to examine the change in symptoms of depression and anxiety after Dobbs (either the June 24, 2022, Dobbs decision, or its May 2, 2022, leaked draft benchmarked to the baseline period, prior to May 2, 2022) by comparing the 13 trigger states with the 37 nontrigger states. Models were estimated for the full population (N = 718 753), and separately for 153 108 females and 102 581 males aged 18 through 45 years. Exposure: Residing in states with trigger laws following the Dobbs decision or its leaked draft. Main Outcomes and Measures: Anxiety and depression symptoms were measured via the Patient Health Questionnaire-4 ([PHQ-4]; range, 0-12; scores of more than 5 indicate elevated depression or anxiety symptoms; minimal important difference unknown). Results: The survey response rate was 6.04% overall, and 87% of respondents completed the PHQ-4. The population-weighted mean age was 48 years (SD, 17 years), and 51% were female. In trigger states, the mean PHQ-4 scores in the baseline period and after the Dobbs decision were 3.51 (95% CI, 3.44 to 3.59) and 3.81 (95% CI, 3.75 to 3.87), respectively, and in nontrigger states were 3.31 (95% CI, 3.27 to 3.34) and 3.49 (95% CI, 3.45 to 3.53), respectively. There was a significantly greater increase in the mean PHQ-4 score by 0.11 (95% CI, 0.06 to 0.16; P < .001) in trigger states vs nontrigger states. From baseline to after the draft was leaked, the change in PHQ-4 was not significantly different for those in trigger states vs nontrigger states (difference-in-differences estimate, 0.09; 95% CI, -0.03 to 0.21; P = .15). From baseline to after the Dobbs opinion, there was a significantly greater increase in mean PHQ-4 scores for those in trigger states vs nontrigger states among females aged 18 through 45 years (difference-in-differences estimate, 0.23; 95% CI, 0.08 to 0.37; P = .002). Among males aged 18 through 45 years, the difference-in-differences estimate was not statistically significant (0.14; 95% CI, -0.08 to 0.36; P = .23). Differences in estimates for males and females aged 18 through 45 were statistically significant (P = .02). Conclusions and Relevance: In this study of US survey data from December 2021 to January 2023, residence in states with abortion trigger laws compared with residence in states without such laws was associated with a small but significantly greater increase in anxiety and depression symptoms after the Dobbs decision.

Trends in Opioid Use Disorder Outpatient Treatment and Telehealth Utilization Before and During the COVID-19 Pandemic.

OBJECTIVE: The authors examined trends in opioid use disorder treatment and in-person and telehealth modalities before and after COVID-19 pandemic onset among patients who had received treatment prepandemic. METHODS: The sample included 13,113 adults with commercial insurance or Medicare Advantage and receiving opioid use disorder treatment between March 2018 and February 2019. Trends in opioid use disorder outpatient treatment, treatment with medications for opioid use disorder (MOUD), and in-person and telehealth modalities were examined 1 year before pandemic onset and 2 years after (March 2019-February 2022). RESULTS: From March 2019 to February 2022, the proportion of patients with opioid use disorder outpatient and MOUD visits declined by 2.8 and 0.3 percentage points, respectively. Prepandemic, 98.6% of outpatient visits were in person; after pandemic onset, at least 34.9% of patients received outpatient care via telehealth. CONCLUSIONS: Disruptions in opioid use disorder outpatient and MOUD treatments were marginal during the pandemic, possibly because of increased telehealth utilization.

Diffusion in the corpus callosum predicts persistence of clinical symptoms after mild traumatic brain injury, a multi-scanner study.

Background: Mild traumatic brain injuries (mTBIs) comprise 80% of all TBI, but conventional MRI techniques are often insensitive to the subtle changes and injuries produced in a concussion. Diffusion tensor imaging (DTI) is one of the most sensitive MRI techniques for mTBI studies with outcome and symptom associations described. The corpus callosum (CC) is one of the most studied fiber tracts in TBI and mTBI, but the comprehensive post-mTBI symptom relationship has not fully been explored. Methods: This is a retrospective observational study of how quantitative DTI data of the CC and its sub-regions may relate to clinical presentation of symptoms and timing of resolution of symptoms in patients diagnosed with uncomplicated mTBI. DTI and clinical data were obtained retrospectively from 446 (mean age 42 years, range 13-82) civilian patients. From patient medical charts, presentation of the following common post-concussive symptoms was noted: headache, balance issues, cognitive deficits, fatigue, anxiety, depression, and emotional lability. Also recorded was the time between injury and a visit to the physician when improvement or resolution of a particular symptom was reported. FA values from the total CC and 3 subregions of the CC (genu or anterior, mid body, and splenium or posterior) were obtained from hand tracing on the Olea Sphere v3.0 SP12 free-standing workstation. DTI data was obtained from 8 different 3T MRI scanners and harmonized via ComBat harmonization. The statistical models used to explore the association between regional Fractional Anisotropy (FA) values and symptom presentation and time to symptom resolution were logistic regression and interval-censored semi-parametric Cox proportional hazard models, respectively. Subgroups related to age and timing of first scan were also analyzed. Results: Patients with the highest FA in the total CC (p = 0.01), anterior CC (p < 0.01), and mid-body CC (p = 0.03), but not the posterior CC (p = 0.91) recovered faster from post-concussive cognitive deficits. Patients with the highest FA in the posterior CC recovered faster from depression (p = 0.04) and emotional lability (p = 0.01). There was no evidence that FA in the CC or any of its sub-regions was associated with symptom presentation or with time to resolution of headache, balance issues, fatigue, or anxiety. Patients with mTBI under 40 had higher FA in the CC and the anterior and mid-body subregions (but not the posterior subregion: p = 1.00) compared to patients 40 or over (p ≤ 0.01). There was no evidence for differences in symptom presentation based on loss of consciousness (LOC) or sex (p ≥ 0.18). Conclusion: This study suggests that FA of the CC has diagnostic and prognostic value for clinical assessment of mTBI in a large diverse civilian population, particularly in patients with cognitive symptoms.

Characteristics and Outcomes of Culture-Positive and Culture-Negative Pediatric Sepsis.

OBJECTIVES: To compare the outcomes of pediatric severe sepsis and septic shock among patients with culture-positive and culture-negative sepsis and to determine if there are differentiating markers of disease severity between these 2 populations during their initial presentation and emergency department (ED) stay. STUDY DESIGN: Retrospective cohort study of patients ≤21 years of age who presented to the ED of a single children's hospital with severe sepsis or septic shock from June 1, 2017 to June 5, 2019. RESULTS: There were 235 patients who met criteria for severe sepsis or septic shock. Of these, 139 (59.1%) had culture-negative sepsis and 96 (40.9%) had culture-positive sepsis. In the adjusted multivariable model, children with culture-negative sepsis had more intensive care unit (ICU)-free days than those with culture-positive sepsis (27.3 vs 24.1; adjusted median differences [aMD] -2.6 [-4.4, -0.8]). There were no differences in mortality or hospital-free days. On initial presentation, there were no differences in fever, hypothermia, tachycardia, tachypnea, or hypotension between the 2 groups. There were no differences in proportion of patients receiving the following interventions: intravenous (IV) antibiotics, IV fluids, vasoactive medications, CPR, intubation, or time from arrival to provision of these interventions. CONCLUSIONS: Culture-negative sepsis constitutes a substantial proportion of pediatric severe sepsis and septic shock. In this study, patients with culture-negative and culture-positive sepsis presented similarly on arrival to the ED and received similar treatments while there. Patients with culture-negative sepsis had more ICU-free days than those with culture-positive sepsis, although differences in hospital length of stay (LOS) and mortality were not observed.

Choice of high-deductible health plans among enrollees with a substance use disorder.

INTRODUCTION: High-deductible health plans (HDHPs) expose enrollees to increased out-of-pocket costs for their medical care, which can exacerbate the undertreatment of substance use disorders (SUDs). However, the factors that influence whether an enrollee with SUD chooses an HDHP are not well understood. In this study, we examine the factors associated with an individual with an SUD's decision to enroll in an HDHP. METHODS: Using de-identified administrative commercial claims and enrollment data from OptumLabs (2007-2017), we identified individuals at employers offering at least one HDHP and one non-HDHP plan. We modeled whether an enrollee chose an HDHP using linear regression on plan and enrollee demographic characteristics. Key plan characteristics included whether a plan had a health savings account (HSA) or a health reimbursement arrangement (HRA). Key demographic variables included age, race/ethnicity, census block income range, census block highest educational attainment, and sex. We separately investigate new enrollment decisions (i.e., not previously enrolled in an HDHP) and re-enrollment decisions, as well as decisions among single enrollees and families of differing sizes. The study also adjusted models for additional plan characteristics, employer and year fixed effects, and census division. Robust standard errors were clustered at the employer level. RESULTS: The sample comprised 30,832 plans and 318,334 enrollees. Among enrollees with new enrollment decisions, 24.6 % chose an HDHP; 93.8 % of HDHP enrollees chose to re-enroll in an HDHP. The study found the presence of a plan HRA to be associated with a higher probability of new and re-enrollment in an HDHP. We found that older enrollees with SUD were less likely to newly enroll in an HDHP, while enrollees who were non-White, living in lower-income census blocks, and living in lower educational attainment census blocks were more likely to newly enroll in an HDHP. Higher levels of health care utilization in the prior year were associated with a lower probability of newly enrolling in an HDHP but associated with a higher probability of re-enrolling. CONCLUSION: Given the emerging evidence that HDHPs may discourage SUD treatment, greater HDHP enrollment could exacerbate health disparities.

High-Deductible Health Plans' Impact on Mental Health and Substance Use Disorder Treatments-Balancing Cost and Care.

This Viewpoint examines the effects of high-deductible health plans (HDHPs) on individuals with mental health and substance use disorders, which is crucial for informing policy and regulatory decisions.

High-deductible Health Plans and Nonfatal Opioid Overdose.

OBJECTIVES: Opioid-related overdose is a public health emergency in the United States. Meanwhile, high-deductible health plans (HDHPs) have become more prevalent in the United States over the last 2 decades, raising concern about their potential for discouraging high-need populations, like those with opioid use disorder (OUD), from engaging in care that may mitigate the probability of overdose. This study assesses the impact of an employer offering an HDHP on nonfatal opioid overdose among commercially insured individuals with OUD in the United States. RESEARCH DESIGN: We used deidentified insurance claims data from 2007 to 2017 with 97,788 person-years. We used an intent-to-treat, difference-in-differences regression framework to estimate the change in the probability of a nonfatal opioid overdose among enrollees with OUD whose employers began offering an HDHP insurance option during the study period compared with the change among those whose employer never offered an HDHP. We also used an event-study model to account for dynamic time-varying treatment effects. RESULTS: Across both comparison and treatment groups, 2% of the sample experienced a nonfatal opioid overdose during the study period. Our primary model and robustness checks revealed no impact of HDHP offer on the probability of a nonfatal overdose. CONCLUSIONS: Our study suggests that HDHP offer was not associated with an observed increase in the probability of nonfatal opioid overdose among commercially insured person-years with OUD. However, given the strong evidence that medications for OUD (MOUD) can reduce the risk of overdose, research should explore which facets of insurance design may impact MOUD use.