Buprenorphine Treatment and Health Reform: Availability, Utilization, and Quality

尽管由于最高法院最近的裁决，各州的执行情况可能会有所不同，但通过 《平价医疗法案》（ACA）预计将对物质使用障碍的治疗产生巨大影响。 (SUD)通过改变治疗筹资方式和更大程度地整合主流保健， SUD治疗。丁丙诺啡治疗阿片类药物使用障碍（OUD）的不断发展的系统是一个主要的 一体化的例子。虽然这一系统在过去十年中有了很大的发展，但研究有限 关于医生如何实施这种拯救生命的治疗，以及他们是否提供与艾滋病毒相关的治疗， 服务目前尚不清楚ACA将如何影响丁丙诺啡治疗的提供。拟议 研究寻求1年的R21支持，以确定研究的可行性，并寻求4年的R33支持， 丁丙诺啡实施情况的纵向研究，该研究整合了关于州一级变化的多层次数据， ACA实施与丁丙诺啡处方医生的纵向调查。的主要目的 R21阶段是确定进行纵向研究的可行性，该研究将医生水平和 国家级数据收集，通过研究程序与4个里程碑，包括建设 的医生样本，调查的发展，通过定性和认知访谈，并产生一个 协议的纵向收集国家一级的数据对ACA的实施。三个具体目标 建议的R33研究是：（1）估计丁丙诺啡利用的横截面和纵向模型 以及实施高质量的临床实践行为（CPB）和艾滋病毒相关服务， 国家背景下的丁丙诺啡治疗 （2）检查相关的 患者支付来源的重要性（例如，医疗补助、私人保险或自付）和其他患者 丁丙诺啡治疗期间医生决策的特征;（3）模拟国家级 ACA的实施与两个国家级结果之间的关联： 医疗补助中的丁丙诺啡以及持有处方X许可证的医生数量 丁丙诺啡这些目标将通过不断收集政策和行政数据来实现 在州一级，对全国代表性的1,200名医生进行4次年度调查， 开丁丙诺啡的许可证这种纵向调查设计将支持实地调查四个独特的联合 分析，每一个都涉及医生决策的一个关键领域，同时也收集CPB数据 随着时间数据分析将包括决策和多层次的横截面多变量模型 对CPB的采用和实施进行纵向分析，以测试理论驱动的假设。通过测量 质量，可用性和利用丁丙诺啡治疗在美国，这项研究可能会确定治疗 可以制定干预措施以改善OUD的治疗质量，同时有助于 关于ACA对美国治疗服务影响的科学知识。

Although its implementation is likely to vary across states due to the recent Supreme Court decision, passage of the Affordable Care Act (ACA) is expected to dramatically impact the delivery of substance use disorder (SUD) treatment through changes to treatment financing and greater integration of mainstream health care and SUD treatment. The evolving system of buprenorphine treatment for opioid use disorders (OUDs) is a prime example of integration. While this system has grown substantially in the past decade, research is limited regarding how physicians are implementing this lifesaving treatment and whether they are delivering HIVrelated services. It is unknown how the ACA will impact the delivery of buprenorphine treatment. The proposed study seeks 1 year of R21 support to establish study feasibility and 4 years of R33 support to conduct a longitudinal study of buprenorphine implementation that integrates multi-level data on state-level variations in ACA implementation with longitudinal surveys of buprenorphine-prescribing physicians. The primary aim of the R21 phase is to determine the feasibility of conducting a longitudinal study that integrates physician-level and state-level data collection, through research procedures linked to 4 milestones encompassing the construction of the physician sample, survey development through qualitative and cognitive interviews, and generation of a protocol for longitudinal collection of state-level data on ACA implementation. The three specific aims of the proposed R33 study are: (1) To estimate cross-sectional and longitudinal models of buprenorphine utilization as well as the implementation of high-quality clinical practice behaviors (CPBs) and HIV-related services in buprenorphine treatment in the context of states implementation of the ACA; (2) To examine the relative importance of patient payment source (e.g., Medicaid, private insurance, or out-of-pocket) and other patient characteristics on physician decision-making during buprenorphine treatment; and (3) To model the state-level associations between the implementation of the ACA and two state-level outcomes: utilization of buprenorphine within Medicaid and the number of physicians holding the X-license for prescribing buprenorphine. These aims will be accomplished through ongoing collection of policy and administrative data at the state-level with 4 annual surveys of a nationally representative sample of 1,200 physicians who hold the X-license to prescribe buprenorphine. This longitudinal survey design will support fielding four unique conjoint analyses, each addressing a key domain of physician decision-making, while also collecting data on CPBs over time. Data analysis will include cross-sectional multivariate models of decision-making and multi-level longitudinal analyses of CPB adoption and implementation to test theory-driven hypotheses. By measuring the quality, availability, and utilization of buprenorphine treatment in the US, this research may identify treatment gaps for which interventions may be developed to improve treatment quality for OUDs while contributing to scientific knowledge regarding the impact of the ACA on US treatment services.