Interest is rapidly growing around screening for health-related social needs (HRSN) in direct patient care settings. The screening and provision of HRSN is often done in the context of trying to address social determinants of health. While there is emerging evidence that screening and referral for HRSN can improve health outcomes, there are educational, operational, and systemic gaps that need to be filled in order for HRSN screening and referral to be implemented system-wide and result in meaningful improvement in population health outcomes. The American College of Preventive Medicine recommends HRSN screening and referral in patient care settings only when there are sufficient systems in place to support addressing those needs. This paper identifies key considerations to take into account when implementing HRSN screening and referral in healthcare settings and makes recommendations to address those key considerations. The recommendations also frame the broader need to address social determinants of health at a population level. Finally, the paper identifies several knowledge and evidence gaps in the existing literature on the topic of HRSN, which will hopefully drive future research in this area, and result in an evidence-based, population approach to the issue.

A novel Oregon Medicaid policy guiding back pain management combined opioid restrictions with emphasis on non-opioid and non-pharmacologic therapies. To examine the effect of the policy on prescribing, health outcomes, and health service utilization. Using Medicaid enrollment, medical and prescription claims, prescription drug monitoring program, and vital statistics files, we analyzed the policy’s association with selected outcomes using interrupted time series models. Adult Medicaid patients with back pain enrolled between 2014 and 2018. The Oregon Medicaid back pain policy. Opioid and non-opioid medication prescribing, procedural care, substance use and mental health conditions, and outpatient and inpatient healthcare utilization. The policy was associated with decreases in the percentage of Medicaid enrollees with back pain receiving any opioids (− 2.68 percentage points [95

Introduction: This study aimed to understand health care providers' experiences implementing the Oregon Back Pain Policy (OBPP) over time. The Medicaid OBPP expanded coverage of evidence-based nonpharmacological therapy (NPT) for back pain and restricted access to opioid therapy and interventional approaches.Methods: The study included six online, asynchronous focus groups with providers in February 2020 (Time 1) and August 2022 (Time 2). Analysis was conducted with a longitudinal, recurrent cross-sectional approach. Analysis occurred in three stages: (1) An immersion/crystallization approach was used to analyze Time 1 focus group data, (2) reflexive thematic analysis was used to analyze Time 2 data, and (3) longitudinal analysis was used to integrate the findings across time points.Results: At Time 1, 48 clinicians and 44 NPT providers participated in the study. Time 2 included 63 clinicians and 59 NPT providers. The longitudinal analysis of the focus group data resulted in four themes: (1) general awareness of the policy, (2) providers support the policy and perceive a benefit to their patients, (3) barriers to NPT accessibility, and (4) barriers to referring patients to NPT.Conclusion: The goal of the OBPP was to improve back pain care for Oregon Medicaid members by increasing access to evidence-based NPT and decreasing reliance on opioid medications. This study revealed that, although clinicians and NPT providers supported the policy, they faced persistent implementation challenges related to referrals, prior authorizations, coverage limitations, low reimbursement rates, and a reduced workforce for NPT providers. In some cases, implementation barriers were removed during the COVID-19 pandemic, but other challenges were more prominent during the pandemic.

Introduction In 2016, Oregon developed an innovative policy to improve care for Medicaid patients with back pain. The objective of this study was to identify factors associated with dose reduction and discontinuation among Medicaid patients using chronic opioid therapy following implementation of this policy. Methods Using Medicaid administrative claims data, this was a retrospective cohort of patients on chronic stable opioid therapy between July and December 2016. Outcomes assessed were 1) 30% reduction in opioid dose and 2) an absolute discontinuation between January to December 2017. Multivariable logistic regressions evaluated association between dose reduction outcomes and clinical and demographic factors. Results Of 4,643 Medicaid patients on chronic opioid therapy, 3853 (83%) had a dose reduction and 651 (14%) discontinued opioids; patients with back pain were more likely to have a dose reduction (adjusted odds ratio [aOR] 1.19; 95% 1.01 to 1.41). Factors associated with discontinuation included having a mental health diagnosis (aOR 1.30; 95% CI 1.08 to 1.56), substance use disorder (aOR 1.90; 95% CI 1.41 to 2.56), opioid use disorder (aOR 1.55; 95% CI 1.21 to 1.99), and receipt of buprenorphine (aOR 2.82; 95% CI 1.30 to 6.15). Discontinuation was less likely in Black patients (aOR 0.50; 95% CI 0.29 to 0.85), in older age groups, and in those with a higher opioid dose at baseline. Conclusions Most Medicaid beneficiaries had a dose reduction following implementation of Oregon's back pain policy. Opioid discontinuation was associated with factors that suggest providers pursue this strategy for patients at higher overdose risk.

Background and Purpose: Despite the lack of proven efficacy, opioids historically have been used for the treatment of noncancer back pain. A variety of other effective therapeutic options for pain management are becoming more available over time. In 2016, Oregon implemented a unique and novel policy to improve evidence-based back pain care and promote safer and more effective opioid prescribing through the state's Medicaid program, the Oregon Health Plan. This article examines the ways providers adapted to providing care for patients with back pain in the context of COVID-19 and to better understand the challenges faced by and adaptations made by providers.Methods: We conducted focus groups with clinicians and physical pain treatment modality practitioners (PPTMPs). In total, 129 providers participated in one of six focus groups, including 74 clinicians (54%) and 55 PPTMPs (42%). Reflexive thematic analysis was used to construct themes or units of meaning across data.Results: Focus groups revealed concerns about PPE shortages, telemedicine challenges, communication barriers, and profession-specific responses to COVID-19, which hindered patient care and referrals. Focus groups also highlighted some advantages related to increased insight into patients' lives, which enhanced treatment. Care during COVID-19 has resulted in continued patient interest in telehealth and telemedicine.Conclusion: Optimizing use of these technologies for health conditions, such as back pain, adds to treatment options for patients and gives providers a more holistic understanding of patients' lives, the challenges they may face, and how that impacts their treatment.

Introduction: In 2016, Oregon developed an innovative policy to improve care for Medicaid patients with back pain. The objective of this study was to identify the factors associated with dose reduction and discontinuation among Medicaid patients using chronic opioid therapy after implementation of this policy. Methods: Using Medicaid administrative claims data, this was a retrospective cohort of patients on chronic stable opioid therapy between July and December 2016. Outcomes assessed were (1) 30% reduction in opioid dose and (2) an absolute discontinuation between January and December 2017. Multivariable logistic regressions evaluated the association between dose reduction outcomes and clinical and demographic factors. Results: Of 4,643 Medicaid patients on chronic opioid therapy, 3,853 (83%) had a dose reduction, and 651 (14%) discontinued opioids; patients with back pain were more likely to have a dose reduction (AOR=1.19; 95% CI=1.01, 1.41). Factors associated with discontinuation included having a mental health diagnosis (AOR=1.30; 95% CI=1.08, 1.56), substance use disorder (AOR=1.90; 95% CI=1.41, 2.56), opioid use disorder (AOR=1.55; 95% CI=1.21, 1.99), and receipt of buprenorphine (AOR=2.82; 95% CI=1.30, 6.15). Discontinuation was less likely in Black patients (AOR=0.50; 95% CI=0.29, 0.85), in older age groups, and in those with a higher opioid dose at baseline. Conclusions: Most Medicaid beneficiaries had a dose reduction after implementation of Oregon's back pain policy. Opioid discontinuation was associated with factors that suggest that providers pursue this strategy for patients at higher overdose risk.

Objective: To increase understanding of referral processes from primary care to integrative and complementary medicine (ICM) under an Oregon Medicaid policy that restricted opioids and expanded access to ICM for back pain patients. Methods: Four asynchronous online focus groups with 48 medical clinicians were conducted. Themes were constructed using thematic analysis. Results: Three themes were constructed related to the clinician's experience: (1) high patient receptivity to ICM, (2) difficulty finding ICM providers who accept Medicaid beneficiaries, and (3) uncertainty of the effectiveness of ICM among clinicians. Conclusions: Findings suggest that health systems expanding access to ICM for Medicaid beneficiaries may benefit from establishing and supporting linkages between clinicians and ICM providers, especially in rural areas.

OBJECTIVES:Oregon Medicaid (Oregon Health Plan, or OHP) implemented an innovative policy in 2016 that increased coverage of evidence-based non-pharmacologic therapies (NPT, including physical therapy, massage, chiropractic, and acupuncture) while restricting opioids, epidural steroid injections, and surgeries. The objective of this study was to compare the perspectives of clinicians who see back pain patients and can prescribe pharmacologic therapies and/or refer to NPTs and clinicians who directly provide NPT therapies affected by the policy. METHODS:A cross-sectional online survey was administered to Oregon prescribing clinicians and NPT clinicians between December 2019 and February 2020. The survey was completed by 107 prescribing clinicians and 83 NPT clinicians. RESULTS:Prescribing clinicians and NPT clinicians had only moderate levels of familiarity with core elements of the policy. Prescribing clinicians had higher levels of frustration caring for OHP patients with back pain than NPT clinicians (83 vs. 34%, p<0.001) and were less confident in their ability to provide effective care (73 vs. 85%, p = .025). Eighty-six percent of prescribing clinicians and 83% of NPT clinicians thought active NPT treatments were effective; 74 and 70% thought passive NPT treatments were effective. Forty percent of prescribing clinicians and 25% of NPT clinicians (p<0.001) thought medically-light therapies were effective, while 29% of prescribing clinicians and 10% of NPT clinicians thought medically-intensive treatments were effective (p=0.001). Prescribing clinicians thought increased access to NPTs improved outcomes, while opinions were less consistent on the impact of restricting opioid prescribing. CONCLUSIONS:Prescribing clinicians and NPT clinicians had varying perspectives of a Medicaid coverage policy to increase evidence-based back pain care. Understanding these perspectives is important for contextualizing policy effectiveness.

INTRODUCTION:Beginning around 2011, innumerable policies have aimed to improve pain treatment while minimizing harms from excessive use of opioids. It is not known whether changing insurance coverage for specific conditions is an effective strategy. We describe and assess the effect of an innovative Oregon Medicaid back/neck pain coverage policy on opioid prescribing patterns.METHODS:This retrospective cohort study uses electronic health record data from a network of community health centers (CHCs) in Oregon to analyze prescription opioid dose changes among patients on long-term opioid treatment (LOT) affected by the policy.RESULTS:Of the 1,789 patients on LOT at baseline, 41.6% had an average daily dose of <20 morphine milligram equivalents (MME), 32.3% had ≥20 to <50 MME, 14.5% had ≥50 to <90 MME, and 11.6% ≥90 MME. Around half of each group discontinued opioids within the 18-month policy period. Those who discontinued did so gradually (average of 11 months) regardless of starting dosage. Predictors of discontinuation included: diagnosis of opioid use disorder, older, non-Hispanic white, and less medical complexity.CONCLUSIONS:Regardless of starting opioid dose, nearly half of patients affected by the 2016 Oregon Medicaid back/neck pain treatment policy no longer received opioid prescriptions by the end of the 18-month study period; another 30% decreased their dose. Gradual dose reduction was typical. These outcomes suggest that the policy impacted opioid prescribing. Understanding patient experiences resulting from such policies could help clinicians and policy makers navigate the complex balance between potential harms and benefits of LOT.

The opioid epidemic has resulted in significant morbidity and mortality in the U.S. Health systems, policymakers, payers, and public health have enacted numerous strategies to reduce the harms of opioids, including opioid use disorder (OUD). Much of this implementation has occurred before the development of OUD‒related comparative effectiveness evidence, which would enable an understanding of the benefits and harms of different approaches. This article from the American College of Preventive Medicine (ACPM) uses a prevention framework to identify the current approaches and make recommendations for addressing the opioid epidemic, encompassing strategies across a primordial, primary, secondary, and tertiary prevention approach. Key primordial prevention strategies include addressing social determinants of health and reducing adverse childhood events. Key primary prevention strategies include supporting the implementation of evidence-based prescribing guidelines, expanding school-based prevention programs, and improving access to behavioral health supports. Key secondary prevention strategies include expanding access to evidence-based medications for opioid use disorder, especially for high-risk populations, including pregnant women, hospitalized patients, and people transitioning out of carceral settings. Key tertiary prevention strategies include the expansion of harm reduction services, including expanding naloxone availability and syringe exchange programs. The ACPM Opioid Workgroup also identifies opportunities for de-implementation, in which historical and current practices may be ineffective or causing harm. De-implementation strategies include reducing inappropriate opioid prescribing; avoiding mandatory one-size-fits-all policies; eliminating barriers to medications for OUD, debunking the myth of detoxification as a primary solo treatment for opioid use disorder; and destigmatizing care practices and policies to better treat people with OUD.

Introduction Online data collection methods can increase study accessibility and ease the burden of data collection for participants. Asynchronous Online Focus Groups are a promising method for data collection among healthcare professionals. Methods In this article, we describe the use of, and lessons learned from conducting 19 Asynchronous Online Focus Groups across four research studies. Results We describe our experiences preparing for, recruiting for, and conducting Asynchronous Online Focus Groups. We highlight decision points around timeframe, eligibility, recruitment, participation, focus group assignment, moderation, and participant engagement. We found that removing geographic barriers was advantageous for collecting data, focus group attrition is a concern for asynchronous formats, and group assignment may affect data. Conclusions Asynchronous Online Focus Groups are a promising method for data collection among healthcare professionals. When conducting Asynchronous Online Focus Groups researchers should consider the suitability and the unique implications of this data collection method for data quality.

Introduction: The objective of this study was to understand the experiences of nonpharmacologic therapy (NPT) providers implementing the Oregon Back Pain Policy (OBPP). The Medicaid OBPP expanded coverage of evidence-based NPTs for back pain and simultaneously restricted access to acute and chronic opioid therapy and some interventional approaches for chronic back pain. Materials and Methods: This study uses a cross-sectional, observational design. The authors conducted three online focus groups with 44 credentialed NPT providers in February 2020. Qualitative data analysis was conducted by a multidisciplinary team with an immersion/crystallization approach. Results: Four themes emerged from the data. Participants reported: (1) a lack of direct communication about the policy and mixed levels of understanding of the policy, (2) belief that expanding access to NPT and restricting opioids was beneficial for patients, (3) implementation challenges that compromised access and the perceived effectiveness of care, and (4) financial challenges in accepting Medicaid referrals, due to reimbursement and administrative burden. Conclusion: The goal of the OBPP was to increase access to evidence-based back pain care, including new coverage of NPT services and decreased opioid prescribing for back pain. This study revealed that although many NPT providers support the goals of this policy, the policy was not communicated systematically to providers and was hampered by implementation challenges.

In 2016, Oregon introduced a policy to improve back pain treatment among Medicaid enrollees by expanding benefits for evidence-based complementary and alternative medical (CAM) services and establishing opioid prescribing restrictions. To examine changes in CAM utilization following the policy and variations in utilization across patient populations. A retrospective study of Oregon Medicaid claims data, examining CAM therapy utilization by back pain patients pre- vs post-policy. We used an interrupted time series analysis to evaluate changes in CAM use and examined the association between patient characteristics and CAM use post-policy using linear regression models. Adult Medicaid patients with back pain. The Oregon Medicaid back pain policy, administered through Coordinated Care Organizations (CCOs). Use of CAM services. Use of any CAM service increased from 7.9% (95% CI 7.6–8.2%) prior to the policy to 30.9% (95% CI 30.4–31.3%) after the policy. Acupuncture increased from 0.3 to 5.6%, chiropractic from 0.3 to 11.1%, massage from 1.6 to 14.8%, PT/OT from 6.0 to 17.7%, and osteopathic from 1.4 to 1.9%. Interrupted time series showed an overall increase in proportion of back pain patients who used CAM service following the policy. Among those who accessed CAM, the policy did not appear to increase the number of services used. In the post period, CAM services were accessed more often by female and older enrollees and urban populations. Black, American Indian/Alaska Native, and Hispanic enrollees were less likely to access CAM services; for Black enrollees, this was true for all types of services. CAM service utilization increased among back pain patients following implementation of Oregon’s policy. There was significant heterogeneity in uptake across service types, CCOs, and patient subgroups. Policymakers should consider implementation factors that might limit impact and perpetuate health disparities.

Background: Primary care physicians are challenged by the need to stay abreast of current research on a wide variety of topics in an environment of time constraints, evolving literature, and misinformation on health topics that are sometimes promulgated to the public. Objective: We sought to identify and discuss common clinical situations encountered in primary care for which medical reversals have occurred. Methods: We recently identified almost 400 medical practices that were used in clinical care before they were tested in well-done randomized controlled trials and subsequently were found to be ineffective or harmful. Results: We review several of these practices commonly used in family medicine, which include arthroscopy for osteoarthritis of the knee, opioids for common causes of pain, and aspirin and continuous positive airway pressure for the prevention of cardiovascular disease. Conclusions: Although these practices were implemented because of sound biologic plausibility or encouraging observational data, well done randomized controlled trials have failed to show evidence of effectiveness. These examples raise caution in introducing new clinical interventions into widespread clinical practice without sufficient high-quality evidence demonstrating efficacy. (c) 2020 The Authors. Published by Elsevier Inc.

Introduction Tobacco use is the leading cause of preventable death and disease in the United States. Oregon's coordinated care model for Medicaid provides an opportunity to consider novel ways to reduce tobacco use. Purpose and Objectives We sought to evaluate the changes in tobacco cessation benefits, patient access to cessation interventions, and cigarette smoking prevalence before and after introduction of the statewide Coordinated Care Organization (CCO) cigarette smoking incentive metric for Medicaid members. Intervention Approach Medicaid and public health collaborated to develop a novel population-level opportunity to reduce tobacco use. In 2016, an incentive metric for cigarette smoking was incorporated into Oregon's CCO Quality Incentive Program, which holds Oregon's CCOs accountable for providing comprehensive cessation benefits and for reducing tobacco use prevalence among members. Evaluation Methods We evaluated the changes in tobacco cessation benefits, patient-provider discussions of smoking cessation, and cigarette smoking prevalence before and after the introduction of the statewide CCO cigarette smoking incentive metric. Results All 15 CCOs now cover cessation counseling (telephone, individual, and group) and pharmacotherapy (all 7 FDA-approved medications). The number of CCOs requiring prior authorization for at least 1 FDA-approved pharmacotherapy decreased substantially From 2016 through 2018, the percentage of Medicaid members who reported that their health care providers recommended cessation assistance increased above baseline. The incentive metric and aligned interventions were associated with a reduction in cigarette smoking prevalence among Medicaid members, as indicated by the electronic health record metric. Thirteen of 15 CCOs demonstrated a reduction in smoking prevalence with the statewide prevalence rate decreased from 29.3% to 26.6%. Implications for Public Health Since incentive metric implementation, progress has been made to reduce tobacco use among CCO members. Cross-agency partnerships between Medicaid and public health contributed to these successes.

Objectives: The authors employ a Whole Systems framework to explore implementation of new guidelines for back and neck pain in Oregon's Medicaid system. Whole Systems research is useful for understanding the relationship between complementary and integrative health care (CIH) and conventional health care systems in real-world clinical and practice settings. Design: Preliminary results are from an observational study designed to evaluate state-wide implementation of CIH and other non-pharmacological treatments for neck and back pain among Oregon Medicaid patients. This natural experiment, even in early stages, provides insight into the challenges of integrating Whole Systems oriented therapies into Medicaid billing and treatment. Methods: Qualitative data are drawn from: (1) semi-structured interviews with representatives of each of the 16 coordinated care organizations (CCOs) responsible for administering the Oregon's Medicaid insurance through the Oregon Health Plan (OHP); and (2) open-ended survey responses from acupuncturists in all 16 CCO areas. Results: Implementation of the new policy guidelines poses logistical and epistemological challenges. Differences in worldview, inadequate reimbursement, and simple lack of awareness of CIH among medical providers are some of the factors that pose barriers to merging CIH therapies into conventional frameworks. Conclusions: In this article, we explore the potential for a Whole Systems perspective to better explain the complexity of integrating CIH and other non-pharmacological services into a state financed health care system. Oregon's expansion of services for back and neck pain presents an opportunity to explore challenges and successes in melding multiple approaches to health and pain management into a managed system such as the OHP.

The ability to identify medical reversals and other low-value medical practices is an essential prerequisite for efforts to reduce spending on such practices. Through an analysis of more than 3000 randomized controlled trials (RCTs) published in three leading medical journals (the Journal of the American Medical Association, the Lancet, and the New England Journal of Medicine), we have identified 396 medical reversals. Most of the studies (92%) were conducted on populations in high-income counties, cardiovascular disease was the most common medical category (20%), and medication was the most common type of intervention (33%).

BACKGROUND:Low- to middle-income countries (LMICs) often have limited budgets for health care, and as such, they need to prioritize health care interventions that are evidence based. However, sometimes, interventions are implemented despite a lack of supporting evidence because of a perceived biologic plausibility or because they have worked in other populations. Later, some of these interventions are shown to either lack benefit or are harmful in randomized studies, which we call a medical reversal.MAIN BODY:In this paper, we discuss a variety of medical reversals in LMICs, ranging from tuberculosis to nutrition to malaria to septic shock. These practices were previously identified, but we wish to highlight those that are most relevant to LMICs.CONCLUSION:Identifying and eliminating these practices will help in better allocation of limited health care resources and dollars in LMICs.