Primary care-based models for Medication-Assisted Treatment (MAT) have been shown to reduce mortality for Opioid Use Disorder (OUD) and have equivalent efficacy to MAT in specialty substance treatment facilities. The objective of this study is to systematically analyze current evidence-based, primary care OUD MAT interventions and identify program structures and processes associated with improved patient outcomes in order to guide future policy and implementation in primary care settings. PubMed, EMBASE, CINAHL, and PsychInfo. We included randomized controlled or quasi experimental trials and observational studies evaluating OUD treatment in primary care settings treating adult patient populations and assessed structural domains using an established systems engineering framework. We included 35 interventions (10 RCTs and 25 quasi-experimental interventions) that all tested MAT, buprenorphine or methadone, in primary care settings across 8 countries. Most included interventions used joint multi-disciplinary (specialty addiction services combined with primary care) and coordinated care by physician and non-physician provider delivery models to provide MAT. Despite large variability in reported patient outcomes, processes, and tasks/tools used, similar key design factors arose among successful programs including integrated clinical teams with support staff who were often advanced practice clinicians (nurses and pharmacists) as clinical care managers, incorporating patient “agreements,” and using home inductions to make treatment more convenient for patients and providers. The findings suggest that multidisciplinary and coordinated care delivery models are an effective strategy to implement OUD treatment and increase MAT access in primary care, but research directly comparing specific structures and processes of care models is still needed.

Strategic purchasing of health care services is widely recommended as a policy instrument. We conducted a review of literature of material drawn from the European Observatory on Health Systems and Policies Health Systems in Transition series, other European Observatory databases, and selected country-specific literature to augment the comparative analysis by providing the most recent healthcare trends in ten selected countries. There is little evidence of purchasing being strategic according to any of the established definitions. There is little or no literature suggesting that existing purchasing mechanisms in Europe deliver improved population health, citizen empowerment, stronger governance and stewardship, or develop purchaser organization and capacity. Strategic purchasing has not generally been implemented. Policymakers considering adopting strategic purchasing policies should be aware of this systemic implementation problem. Policymakers in systems with strategic purchasing built into policy should not assume that a purchasing system is strategic or that it is delivering any expected objectives. However, there are individual components of strategic purchasing that are worth pursuing and can provide benefits to health systems.

Policy Points: Strategically purchasing health care has been and continues to be a popular policy idea around the world. Key asymmetries in information, market power, political power, and financial power hinder the effective implementation of strategic purchasing. Strategic purchasing has consistently failed to live up to its promises for these reasons. Future strategies based on strategic purchasing should tailor their expectations to its real effectiveness. Context: Strategic purchasing of health care has been a popular policy idea around the world for decades, with advocates claiming that it can lead to improved quality, patient satisfaction, efficiency, accountability, and even population health. In this article, we report the results of an inquiry into the implementation and effects of strategic purchasing.Methods: We conducted three in‐depth case studies of England, the Netherlands, and the United States. We reviewed definitions of purchasing, including its slow acquisition of adjectives such asstrategic, and settled on a definition of purchasing that distinguishes it from the mere use of contracts to regulate stable interorganizational relationships. The case studies review the career of strategic purchasing in three different systems where its installation and use have been a policy priority for years.Findings: No existing health care system has effective strategic purchasing because of four key asymmetries: market power asymmetry, information asymmetry, financial asymmetry, and political power asymmetry.Conclusions: Further investment in policies that are premised on the effectiveness of strategic purchasing, or efforts to promote it, may not be worthwhile. Instead, policymakers may need to focus on the real sources of power in a health care system. Policy for systems with existing purchasing relationships should take into account the asymmetries, ways to work with them, and the constraints that they create.

Compound threats—two or more relatively rare and high-consequence events that co-occur in time and space, amplifying their effects—present difficult-to-predict events that can impose potentially grave consequences. While there has been increasing attention placed on modeling the probabilities and outcomes of compounding threats, there are no proposed governance models for compound threats, limiting the ability of policymakers and decisionmakers to manage such crises in the future. We visualize resilience for compound threats to understand how critical functioning and system utility to contain hazards, to absorb losses, and to recover from stressors shifts over time. Using North Carolina as a case study, we conduct a compound threats assessment for disaster risk to showcase its effectiveness in more accurately predicting disaster risk areas, as well highlight the limitations of existing risk models used by policymakers. We propose a resilience-augmented conceptual framework to rethink risk governance for compound threats that allows for speed (specifically flexibility and adaptability) in situations of high uncertainty while working within the rigid, slow-moving boundaries of government and bureaucracy. Finally, we discuss strategies for key actors to apply a resilience-augmented governance approach to compound threats into operational decision-making during crisis situations.

Background: Hurricanes Katrina and Sandy were two of the most significant disasters of the 21^st century that critically impacted communities and the health of their residents. Despite the assumption that disasters affect access to healthcare, to our knowledge prior studies have not rigorously examined availability of healthcare providers following disasters. Objective: The objective of this study was to examine availability of healthcare providers following large-scale hurricanes. Methods: Using historical data on healthcare providers from the National Plan and Provider Enumeration System and county-level population characteristics, we conducted a quasi-experimental study to examine the effect of large-scale hurricanes on healthcare provider availability in the short-term and long-term. We separately examined availability of primary care physicians, medical specialists, surgeons, and nurse practitioners. A difference-in-differences analysis was used to control for time variant factors comparing county-level health care provider availability in affected and unaffected counties the year before Hurricanes Katrina and Sandy, to five years after each storm. Results: Counties affected by Hurricane Katrina compared to unaffected locales experienced a decrease of 3.59 primary care physicians per 10,000 population (95% CI: -6.5, -0.7), medical specialists (decrease of 5.9 providers per 10,000 (95% CI: -11.3, -0.5)), and surgeons (decrease of 2.1 (95% CI: -3.8, -0.37)). However, availability of nurse practitioners did not change appreciably. Counties affected by Hurricane Sandy exhibited less pronounced changes. Changes in availability of primary care physicians, nurse practitioners, medical specialists, and surgeons were not statistically significant. Conclusion: Large-scale hurricanes appear to affect availability of healthcare providers for up to several years following impact of the storm. Effects vary depending on the characteristics of the community. Primary care physicians and medical specialists availability was the most impacted, potentially having long-term implications for population health in the context of disaster recovery.