Philadelphia, Pennsylvania, is an burghal epicenter of the opioid epidemic, and inappropriate opioid prescribing charcoal a top concern. To advice abode this issue, the Philadelphia Medicaid Opioid Prescribing Initiative, a blazon of association affection collaborative, mailed bags of bounded Medicaid providers an abundant prescribing abode agenda in 2017 and 2018. The abode agenda featured capacity of providers’ opioid prescribing, including associate allegory measures and inappropriate prescribing measures like accessory opioid and benzodiazepine prescribing. This case abstraction describes the different action of developing and distributing the opioid prescribing abode cards, with a accurate focus on the role of Medicaid managed affliction organizations. Application Medicaid pharmacy claims, the all-encompassing aberration in prescribing measures aural and beyond specialties is additionally illustrated. The abode card’s accomplishing credibility to the abeyant amount of collaborations amid accessible bloom departments and Medicaid managed affliction organizations and can accommodate acumen for added locally developed policies.
Am J Manag Care. 2021;27(12):e429-e434. https://doi.org/10.37765/ajmc.2021.88798
This commodity describes the Philadelphia Medicaid Opioid Prescribing Action that was launched by a multidisciplinary aggregation and mailed bounded Medicaid providers abundant prescribing abode cards.
Philadelphia, Pennsylvania, is an burghal epicenter of the opioid epidemic.1 Heroin and constructed opioids such as fentanyl resulted in added than 1000 balance deaths in Philadelphia in 2019, apery one of the accomplished afterlife ante amid city areas in the United States.2 Beyond mortality, opioid use ataxia (OUD) has extensive after-effects beyond the community, with links to bent amends involvement3 and college ante of neonatal abnegation affection and advance care placements.4,5
For abounding patients with OUD, their aboriginal acquaintance with opioids was not illicit. Instead, it occurred in a physician’s appointment with a acknowledged decree for opioids.6 Billions of opioid prescriptions accept been accounting in the accomplished few decades, and surveys abode that advancement of 80% of new heroin users began with decree opioids.7,8 Although abounding of these prescriptions attach to analytic guidelines, others needlessly abode patients (and their ancestors and friends9) at added accident of developing OUD.10
To barrier inappropriate opioid prescriptions, countless state-level behavior accept been alien (eg, pharmacies acute patients to appearance identification to aces up opioid decree fills).11 Yet states can be apathetic to apparatus behavior that accept been apparent to be effective. For example, it took added than a decade for some states to convention decree biologic ecology programs (PDMPs).12
Locally developed behavior may action some advantages, including institutional ability of basal citizenry problems and absolute relationships beyond stakeholder groups. One contempo archetype is Philadelphia’s Medicaid Opioid Prescribing Initiative, which was advised to advance the account of opioid prescriptions in Philadelphia County. Abounding of the participants were already alive calm on added accessible bloom initiatives in the county. Its aboriginal assignment was instituting a achievement acknowledgment action in which bags of bounded Medicaid providers accustomed customized abode cards account their opioid prescribing about to their peers.
Here we present capacity of this association affection collaborative, which included accessible bloom admiral and Medicaid managed affliction organizations.13 This case abstraction credibility to the abeyant amount of county-level accord in active the opioid epidemic, decidedly the different role of managed affliction organizations, and provides acumen for added action interventions instituted at a bounded level. To our knowledge, Philadelphia is the aboriginal city to advance and bear its own opioid prescribing abode card.
Public and clandestine advertisement on the achievement of bloom affliction providers is accepted practice.14 Whereas accessible advertisement is generally acclimated to acquaint patients about the affection of bloom affliction services, clandestine advertisement tends to ambition providers.14 A accepted blazon of clandestine advertisement is achievement feedback, which is sometimes presented in abode cards.15 Achievement acknowledgment has been abundantly studied, and a assay of randomized trials credibility to a absolute aftereffect overall.16,17 However, the success of achievement acknowledgment depends on providers’ baseline achievement and the method, source, and continuance of feedback.18
The aloft barrier to implementing achievement acknowledgment is the availability of absolute advice apropos provider performance. For opioid prescribing, PDMPs are one abeyant antecedent of authoritative data. Since the admission of the opioid epidemic, the cardinal of states instituting PDMPs has developed rapidly, with programs now operational in about every state.19 Yet alone a few states accept launched abode cards application this information, and there is a absence of bookish abstract on the accomplishing and appulse of abode cards application PDMPs.19
Another antecedent of achievement acknowledgment is authoritative abstracts calm by insurers and managed affliction organizations (MCOs).20 A growing cardinal of accompaniment Medicaid programs are creating achievement acknowledgment initiatives, and abounding are involving Medicaid MCOs, which are additionally encouraged to acquaint affection advance programs.21 However, in states such as Pennsylvania, Medicaid MCOs are operated at the canton level, presenting an authoritative barrier to implementing statewide programs.22
Developing the Abode Cards
In 2017, Association Behavioral Bloom (CBH), the behavioral bloom MCO in Philadelphia Canton for Medicaid enrollees, approached Pennsylvania’s Appointment of Medical Abetment Programs to altercate the charge to adviser opioid prescribing in Philadelphia. CBH was experiencing an added appeal for actuality use ataxia treatment. Informal investigations appear inappropriate prescribing practices, such as the circumstantial use of opioids and methadone maintenance.
Like several added states, Pennsylvania “carves out” behavioral bloom from concrete health, and accompaniment Medicaid admiral were absorbed in acknowledging CBH in developing a apparatus that could subsequentially be taken over by the state’s PDMP. CBH was in a different position to advance the abode agenda action because it was the sole behavioral bloom MCO in Philadelphia, with abreast Medicaid accommodation records, pharmacy claims, and concrete bloom claims, in accession to behavioral bloom claims for the county’s Medicaid population. By comparison, there were 4 concrete bloom MCOs that could admission alone the claims of their Medicaid enrollees.
Report cards were envisioned as a commutual action to the PDMP. Although providers could chase for opioid prescriptions of their patients application the PDMP, abounding were not actively application the resource.23 Alike back they did use the PDMP, providers could not analyze their own prescribing with that of their peers, nor could they see all controlled substances. Prior to Act 191 of 2014, Pennsylvania’s PDMP appear Schedule II controlled substances only. Also, prescriptions for benzodiazepines, a Schedule IV controlled substance, were reportable alpha in 2017.24
After accepting abutment from accompaniment officials, CBH convened a activity aggregation of stakeholders beyond Philadelphia, including Philadelphia’s Department of Accessible Bloom and Department of Behavioral Bloom and Bookish disAbility Services, the 4 concrete bloom Medicaid MCOs, and advisers from the University of Pennsylvania’s Center for Mental Bloom (“Penn”). CBH created an centralized administration aggregation consisting of physicians, pharmacists, epidemiologists, bloom economists, and abstracts managers. It additionally appointed an authoritative abettor to alike the project’s activities.
The activity aggregation associates agreed that abode cards could advice abutting gaps in advice apropos providers’ prescribing, but they acquainted that the abode agenda should be educational rather than punitive. To architecture the abode card, advisers from Penn advised the abstract on absolute abode agenda initiatives and performed basic analyses of the pharmacy claims. The abstract assay articular a abstruse abetment abode able by Brandeis University advisers that included templates of opioid abode cards, which were developed by several states in affiliation with their PDMPs.19 Arizona’s archetypal served as the base for Philadelphia’s abode because it had architecture appearance and measures that were constant with the interests of the activity team. It consisted of a distinct folio announcement assorted prescribing measures, some with associate comparison.
In accession to accumulated opioid prescribing, added measures were considered. The aggregation was absorbed in benzodiazepine prescribing and accessory opioid-benzodiazepine prescribing. Since 2012, added than 2000 balance deaths in Philadelphia accept circuitous benzodiazepines, which are amid the best abused consciousness-expanding drugs and should not be acclimated accordingly with opioids due to an added accident of respiratory depression.25 The aggregation additionally added high-dose opioid prescribing as a measure. Analytic guidelines advance a circadian dosage lower than 50 to 90 morphine milligram equivalents (MME), but abstraction after-effects accept apparent that about 15% of patients accept higher-than-recommended doses.10 A final admeasurement flagged opioid prescriptions to patients with a history of actuality use treatment.
Once measures were agreed upon, the alignment for amalgam associate allegory was determined. The aggregation acclimated the National Provider Identifiers, amid in pharmacy claims, and affiliated them to self-identified anatomy codes of specialties in the National Plan and Provider Enumeration Arrangement (NPPES). A accumulation of physicians, pharmacists, and epidemiologists at CBH aggregate 266 specialties into 27 broader categories application the Bloom Affliction Prescriber Anatomy Code and Specialty bridge from the National Uniform Claim Committee.
Providers accustomed a abode agenda alone if they assigned opioids to 10 or added Medicaid patients over a 12-month period. Any decree accounting to Philadelphia Medicaid enrollees could be included in the abode cards, alike if providers did not convenance in Philadelphia County.
Implementing the Abode Card
Over the advance of a few months, the activity aggregation agreed on a abode agenda architecture (Figure). For the aboriginal 6 measures, abode cards included a baronial arrangement for associate allegory purposes. Abstracts were aggregated aural specialties and a beggarly and SD were estimated. Rankings were categorized as acute (3 SDs aloft the mean), astringent (2 SDs aloft the mean), aerial (1 SD aloft the mean), and accustomed (the beggarly or below). Providers who assigned opioids to beneath than 10 patients were still included in associate allegory calculations.
The aboriginal abundance of abode cards was mailed in December 2017 to 2632 providers. The mailings included recommendations for best prescribing practices from the CDC and advice on an accessible continuing medical apprenticeship affairs focused on evidence-based accoutrement to action the opioid epidemic.26 Links to the PDMP and a account of Philadelphia’s actuality use assay providers were additionally included.
Report cards independent acquaintance advice for the Department of Accessible Health, area comments and questions could be submitted. All acknowledgment was advised by the pharmacy administrator and medical administrator at CBH. Beneath than 10 providers responded, with some adage that the abode cards included admired information. Providers additionally referred to a key limitation: Abode cards included alone Medicaid patients. Although Medicaid patients accept been disproportionally afflicted by the opioid epidemic,27 the providers argued that prescribing abode cards would be added allusive if they included a provider’s complete accommodating panel. This would accept been accessible had the abstracts antecedent been Pennsylvania’s PDMP or an all-payer claims database, the closing of which is growing in acceptance but has not been acclimated broadly for achievement feedback.28
After the aboriginal mailing, the activity aggregation redesigned some aspects of the abode card. Inconsistencies beyond after-effects accomplish an appraisal added complex, so alone 3 changes were ultimately instituted: abode cards included 6 months of prescribing rather than 12; the beginning of 90 MME/day was bargain to 50 MME/day; and the admeasurement of opioid prescriptions abiding best than 7 canicule was added. An boundless continuance of opioid prescriptions was accession affair because there is little affirmation of the capability of opioids for noncancer affliction in the continued term.29 In July 2018, a added beachcomber of prescribing abode cards was beatific to 1495 providers.
Results From the Abode Cards
Report cards appear abundant aberration in opioid prescribing, highlighting why opioid-related behavior cannot be one admeasurement fits all. While a provider’s associate allegory assay could be accustomed for one admeasurement and acute for another, specialties explained abundant of the aberration in prescribing (Table). The beggarly cardinal of Medicaid patients bushing an opioid decree over 12 months (among all Medicaid providers who assigned at atomic 1 opioid or benzodiazepine) was alone 0.6 for psychiatry but college in affliction anesthetic (20.5 patients), emergency anesthetic (11.8 patients), and anaplasty (43.1 patients for surgical dentists, 18.0 for surgical podiatrists, and 12.9 for accepted surgeons). Benzodiazepine prescribing, which was additionally included in abode cards, was accepted in psychiatry (28.8 patients on average) and rarer in affliction anesthetic (2.8 patients), emergency anesthetic (2.0 patients), and anaplasty (0.2 patients for surgical dentists, 0.2 for surgical podiatrists, and 0.6 for accepted surgeons).
Inappropriate prescribing measures showed agnate variation. Amid the subset of providers who met the 10-patient beginning to accept abode cards, the allotment of patients bushing circumstantial opioid-benzodiazepine prescriptions ranged from beneath than 10% to about 50% beyond specialties. High-dose opioid prescriptions occurred beneath frequently. The amount of opioid prescribing to patients with actuality use ataxia assay was the everyman (< 20% beyond all specialties). The abrupt adverse suggests that interventions aimed at inappropriate opioid prescribing may charge to be tailored for specialties.
The accession of abode cards in Philadelphia Canton illustrates the abeyant trade-offs circuitous in state- vs county-level initiatives. On the one hand, interventions may be slower to apparatus by states accustomed the added cardinal of stakeholders and aggressive priorities. The abate admeasurement of bounded governments agency beneath stakeholders, abounding with absolute relationships, appropriately authoritative affection advance interventions easier to implement. For example, CBH was already a affiliate of the Philadelphia Opioid Assignment Force in 2017, which gave it accessible admission to accessible bloom officials.
On the added hand, state-level initiatives account from beyond budgets and abstracts basement that can abutment the development and sustainability of programs. The use of the PDMP to actualize provider abode cards would acquiesce for prescriptions from assorted insurers to be used. Perhaps the best book is a affiliation amid accompaniment and bounded organizations, an admission that was acclimated by Pennsylvania Medicaid during the development of a dashboard for antipsychotic prescribing to adolescence in advance care.30 In this program, accouchement with inappropriate prescriptions are flagged by the state, again followed up by the county’s Medicaid MCO as allotment of its affection advance efforts.
Some limitations are account noting. Abode cards included alone prescriptions abounding and reimbursed by Philadelphia Medicaid, and some specialties had few providers, which can be ambiguous for associate comparison. In addition, a baby cardinal of providers claimed that their specialty was inaccurate (although regulations crave providers to amend the NPPES aural 30 canicule of any changes, it appeared that some providers had not done so31). Also, some measures circuitous assorted providers, such as circumstantial opioid-benzodiazepine prescribing, which can attenuate abundant interventions. For example, assistant practitioners or physician administration may accept been the appointed prescribers for physicians (in Pennsylvania, assistant practitioners charge attach to a accounting collaborative acceding with physicians to prescribe32). Finally, the abode cards issued to prescribers had no banking incentives but were meant to admission acquaintance and accommodate a allegory that would adviser added practice.
Critical questions remain, including about the abode cards’ effectiveness. An appraisal application adjoining counties as a allegory accumulation is in progress. There are additionally questions of cost-effectiveness, although abode cards are almost low amount compared with added types of achievement feedback, which can absolve alike baby changes in prescribing outcomes.33 Added abeyant after-effects accommodate barter to nonopioid affliction medications or abnormal cone-shaped from opioids and benzodiazepines that precipitates withdrawal, which can be alarming to patients.
There is additionally the COVID-19 catching to consider, which acquired aloft disruptions as providers acutely bound contiguous visits.34 COVID-19 may accept affronted the opioid catching due to the affecting bead in bloom affliction utilization, including the accouterment of medication-assisted assay and the accident of employer-sponsored insurance.35,36 There are apropos that a absolute storm is looming as approaching accompaniment account shortfalls put added burden on public-sector programs to accommodate casework such as actuality use ataxia treatment.37 As with the opioid epidemic, COVID-19 requires tailored responses to prevention, testing, and vaccination, which may account from absolute association affection collaboratives. Medicaid MCOs are in a different position to advice municipalities respond, accustomed their admission to rich, abreast patient-level information.
In the meantime, inappropriate opioid prescribing charcoal a top affair and municipalities are demography atypical approaches to abode it. The Philadelphia Medicaid Opioid Prescribing Initiative, a association affection collaborative involving the Philadelphia Department of Accessible Bloom and Medicaid MCOs, demonstrates the abeyant amount of these approaches.
Author Affiliations: Center for Mental Health, University of Pennsylvania (SS, MC, DSM, OO, AR), Philadelphia, PA; Association Behavioral Bloom (OF, KK, CT), Philadelphia, PA; Department of Behavioral Bloom and Bookish disAbility Casework (SL), Philadelphia, PA; Association Affliction Behavioral Bloom Organizations (GN), Pittsburgh, PA; Philadelphia Department of Accessible Bloom (LNP, RW), Philadelphia, PA; School of Social Action and Practice, University of Pennsylvania (AR), Philadelphia, PA.
Source of Funding: None.
Author Disclosures: Ms Shen, Dr Candon, and Dr Rothbard accustomed bacon abutment from a casework arrangement with Association Behavioral Bloom and Penn Center for Mental Health. Dr Neimark owns shares of Pfizer. Ms Shen, Dr Candon, and Dr Rothbard are active by the Center for Mental Health, which receives funds to accomplish QA and evaluation. The actual authors abode no accord or banking absorption with any commodity that would affectation a battle of absorption with the accountable amount of this article.
Authorship Information: Concept and architecture (SS, MC, OF, KK, DSM, GN, LNP, RW, AR); accretion of abstracts (KK, SL, CT, RW); assay and estimation of abstracts (SS, MC, OF, LNP, RW, AR); drafting of the arrangement (SS, MC, OF, DSM, RW, AR); analytical afterlight of the arrangement for important bookish agreeable (SS, MC, OF, SL, GN, OO, LNP, CT, RW, AR); statistical assay (SS); accouterment of patients or abstraction abstracts (OF); accepting allotment (CT); administrative, technical, or logistic abutment (SS, MC, OF, KK, SL, DSM, GN, OO, CT, RW); and administration (MC, OF, GN, OO, CT, AR).
Address Correspondence to: Siyuan Shen, MCIT, Center for Mental Health, University of Pennsylvania, 3535 Market St, 3rd Fl, Rm 3087, Philadelphia, PA 19104. Email: Lisa.Shen@pennmedicine.upenn.edu.
1. Whelan A. How Philly affairs to action the nation’s affliction big-city opioid crisis in 2020. The Philadelphia Inquirer. January 21, 2020. Accessed January 22, 2021. https://www.inquirer.com/health/opioid-addiction/whats-next-2020-opioid-crisis-overdoses-philadelphia-kensington-20200121.html
2. Basal account of afterlife 1999-2017. CDC WONDER Online Database. 2018. Accessed January 22, 2021. https://wonder.cdc.gov/Deaths-by-Underlying-Cause.html
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4. Patrick SW, Davis MM, Lehmann CU, Cooper WO. Increasing accident and geographic administration of neonatal abnegation syndrome: United States 2009 to 2012. J Perinatol. 2015;35(8):650-655. doi:10.1038/jp.2015.36
5. Radel L, Baldwin M, Crouse G, Ghertnew R, Waters A. Actuality use, the opioid epidemic, and the adolescent abundance system: key allegation from a alloyed methods study. Appointment of the Abettor Secretary for Planning and Evaluation, HHS. March 7, 2018. Accessed January 22, 2021. https://aspe.hhs.gov/sites/default/files/migrated_legacy_files//179966/SubstanceUseChildWelfareOverview.pdf
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7. Muhuri PK, Gfroerer JC, Davies MC. Associations of nonmedical affliction analgesic use and admission of heroin use in the United States. Actuality Corruption and Mental Bloom Casework Association. August 2013. Accessed January 22, 2021. https://www.samhsa.gov/data/sites/default/files/DR006/DR006/nonmedical-pain-reliever-use-2013.htm
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11. Menu of accompaniment decree biologic identification laws. CDC. Accessed December 12, 2018. https://www.cdc.gov/phlp/docs/menu-pdil.pdf
12. Abstruse abetment guide: history of decree biologic ecology programs. Decree Biologic Ecology Affairs Training and Abstruse Abetment Center. March 2018. Accessed December 12, 2018. https://www.pdmpassist.org/pdf/PDMP_admin/TAG_History_PDMPs_final_20180314.pdf
13. Shaller D, Kanouse D. Clandestine “performance feedback” advertisement for physicians: advice for association affection collaboratives. Agency for Healthcare Research and Affection advertisement No. 13-0004. November 2012. Accessed December 12, 2018. https://www.ahrq.gov/sites/default/files/publications/files/privfeedbackgdrpt.pdf
14. Faber M, Bosch M, Wollersheim H, Leatherman S, Grol R. Accessible advertisement in bloom care: how do consumers use quality-of-care information? a analytical review. Med Care. 2009;47(1):1-8. doi:10.1097/MLR.0b013e3181808bb5
15. McNamara P, Shaller D, De La Mare D, Ivers N. Confidential physician acknowledgment reports: designing for optimal appulse on performance. Agency for Healthcare Research and Affection advertisement No. 16-0017-EF. March 2016. Accessed December 12, 2018. https://www.ahrq.gov/sites/default/files/publications/files/confidreportguide_0.pdf
16. Campanella P, Vukovic V, Parente P, Sulejmani A, Ricciardi W, Specchia ML. The appulse of accessible advertisement on analytic outcomes: a analytical assay and meta-analysis. BMC Bloom Serv Res. 2016;16:296. doi:10.1186/s12913-016-1543-y
17. Ivers N, Jamtvedt G, Flottorp S, et al. Analysis and feedback: furnishings on able convenance and healthcare outcomes. Cochrane Database Syst Rev. 2012;(6):CD000259. doi:10.1002/14651858.CD000259.pub3
18. Soumerai SB, McLaughlin TJ, Avorn J. Improving biologic prescribing in primary care: a analytical assay of the beginning literature. Milbank Q. 1989;67(2):268-317.
19. Abstruse abetment guide: prescriber abode cards. Decree Biologic Ecology Affairs Training and Abstruse Abetment Center. March 15, 2016. Accessed July 10, 2017. http://2m2q501o69ol2wiszw2thkas-wpengine.netdna-ssl.com/wp-content/uploads/2016/11/Report_Card_TAG_20160315_final.pdf
20. 2016 QRUR and 2018 amount modifier. CMS. Updated July 26, 2019. Accessed January 1, 2020. https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/PhysicianFeedbackProgram/2016-QRUR
21. Gadbois EA, Gordon SH, Shield RR, Vivier PM, Trivedi AN. Affection administration strategies in Medicaid managed care: perspectives from Medicaid, plans, and providers. Med Affliction Res Rev. 2021;78(1):36-47. doi:10.1177/1077558719841157
22. Managed affliction in Pennsylvania. Medicaid.gov. Accessed January 20, 2020. https://www.medicaid.gov/medicaid-chip-program-information/by-topics/delivery-systems/managed-care/downloads/pennsylvania-mcp.pdf
23. Leichtling GJ, Irvine JM, Hildebran C, Cohen DJ, Hallvik SE, Deyo RA. Clinicians’ use of decree biologic ecology programs in analytic convenance and decision-making. Pain Med. 2017;18(6):1063-1069. doi:10.1093/pm/pnw251
24. Achieving Better Affliction by Ecology All Prescriptions Affairs (ABC-MAP) Act – Enactment. Pennsylvania Accepted Assembly. October 27, 2014. Accessed December 12, 2018. https://www.legis.state.pa.us/cfdocs/legis/li/uconsCheck.cfm?yr=2014&sessInd=0&act=191
25. Schmitz A. Benzodiazepine use, misuse, and abuse: a review. Ment Bloom Clin. 2016;6(3):120-126. doi:10.9740/mhc.2016.05.120
26. About CDC’s Opioid Prescribing Guideline. CDC. February 17, 2021. Accessed March 30, 2021. https://www.cdc.gov/drugoverdose/prescribing/guideline.html
27. Orgera K, Tolbert J. The opioid catching and Medicaid’s role in facilitating admission to treatment. Kaiser Ancestors Foundation. May 24, 2019. Accessed January 22, 2021. https://www.kff.org/medicaid/issue-brief/the-opioid-epidemic-and-medicaids-role-in-facilitating-access-to-treatment/
28. Bardach NS, Lin GA, Wade E, et al. All-payer claims databases altitude of care: analytical assay and ecology browse of accepted practices and evidence. Agency for Healthcare Research and Quality. June 2017. Accessed January 22, 2021. https://www.ahrq.gov/sites/default/files/publications/files/envscanlitrev.pdf
29. Chou R, Turner JA, Devine EB, et al. The capability of abiding opioid assay for abiding pain: a analytical assay for a National Institutes of Bloom Pathways to Blockage Workshop. Ann Intern Med. 2015;162(4):276-286. doi:10.7326/M14-2559
30. Malone M, Zlotnik S, Miller D, Kreider A, Rubin D, Noonan K. Consciousness-expanding medication use by Pennsylvania accouchement in advance affliction and enrolled in Medicaid: an assay of accouchement ages 3-18 years. Children’s Hospital of Philadelphia PolicyLab. 2015. Accessed December 12, 2018. https://policylab.chop.edu/sites/default/files/Psychotropic_Medication_Use_by_PA_Children_in_Foster_Care_and_Medicaid_Spring_2015.pdf
31. CMS, HHS. HIPAA authoritative simplification: accepted different bloom identifier for bloom affliction providers; final rule. Fed Regist. 2004;69(15):3434-3469.
32. Pennsylvania accompaniment action actuality sheet. American Association of Assistant Practitioners. 2019. Accessed January 1, 2020. https://www.aanp.org/advocacy/state/state-practice-environment/state-policy-fact-sheets/pennsylvania-state-policy-fact-sheet
33. Flottorp SA, Jamtvedt G, Gibis B, McKee M. Application analysis and acknowledgment to bloom professionals to advance the affection and assurance of bloom care. World Bloom Organization. 2010. Accessed December 12, 2018. https://www.euro.who.int/__data/assets/pdf_file/0003/124419/e94296.pdf
34. Haley DF, Saitz R. The opioid catching during the COVID-19 pandemic. JAMA. 2020;324(16):1615-1617. doi:10.1001/jama.2020.18543
35. Vaccaro AR, Getz CL, Cohen BE, Cole BJ, Donnally CJ III. Convenance administration during the COVID-19 pandemic. J Am Acad Orthop Surg. 2020;28(11):464-470. doi:10.5435/JAAOS-D-20-00379
36. Acs G, Karpman M. Employment, income, and unemployment allowance during the COVID-19 pandemic. Burghal Institute. June 2020. Accessed January 22, 2021. https://www.urban.org/sites/default/files/publication/102485/employment-income-and-unemployment-insurance-during-the-covid-19-pandemic.pdf
37. Temporary added federal Medicaid allotment can abate the bread-and-butter draft of the COVID-19 communicable on states, but is absurd to absolutely account accompaniment acquirement declines or apprehend account shortfalls. News release. Kaiser Ancestors Foundation; July 22, 2020. Accessed January 22, 2021. https://www.kff.org/coronavirus-covid-19/press-release/temporary-enhanced-federal-medicaid-funding-can-soften-the-economic-blow-of-the-covid-19-pandemic-on-states-but-is-unlikely-to-fully-offset-state-revenue-declines-or-forestall-budget-shortfalls/
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