Race, Managed Care, And The Quality Of Substance Abuse Treatment

Access to medication for opioid use disorder supported by telemedicine and healthcare coverage: A web-based survey during the COVID-19 pandemic

Background and Aims

Medications for opioid use disorder (MOUD) are highly effective in improving treatment outcomes and reducing overdose. Concerns about interrupted access to critical MOUD services led to expansion of telemedicine services during the COVID-19 pandemic in the US. The current study tested the hypothesis that telemedicine usage and healthcare coverage would be significantly associated with access to MOUD in the early phase of the COVID-19 pandemic.

Design

A cross-sectional online survey was administered to a non-probability sample from June 18-July 19, 2020 using the Amazon Mechanical Turk platform.

Setting

Northeastern United States during the early phase of the COVID-19 pandemic. At the time of the survey, federal regulators had waived the longstanding requirement for in-office visits for MOUD prescription receipt and provided guidance on increasing third-party payer reimbursement rates for telehealth visits in order to mitigate barriers to care associated with COVID-19 safety guidelines.

Participants

Individuals 18 years or older residing in Connecticut, Massachusetts, New Jersey, New York, or Rhode Island were eligible to complete the survey. The analytic sample was participants who reported using opioids not as prescribed by a physician in the past seven days.

Measurements

Demographics, telemedicine usage, and healthcare coverage were assessed as explanatory variables. The primary outcome was whether participants reported ability to access MOUD in the past four weeks.

Findings

In this sample of individuals who used illicit opioids in the past week (N = 191), one in two individuals who utilized telehealth or had healthcare coverage were able to access MOUD, whereas only one in five of their respective counterparts who did not have telehealth access or healthcare coverage were able to access these medications.

Conclusions

Telemedicine and healthcare coverage were associated with greater MOUD access early in the COVID-19 pandemic, when barriers to care were high. Such findings speak to the importance of not only extending but also formalizing temporary policy changes instituted during the pandemic to allow MOUD prescribing via telemedicine.

Racial/Ethnic Disparities in Substance Use Treatment in Medicaid Managed Care in New York City: The Role of Plan and Geography

OBJECTIVE

The aim was to assess the magnitude of health care disparities in treatment for substance use disorder (SUD) and the role of health plan membership and place of residence in observed disparities in Medicaid Managed Care (MMC) plans in New York City (NYC).

DATA SOURCE

Medicaid claims and managed care plan enrollment files for 2015-2017 in NYC.

RESEARCH DESIGN

We studied Medicaid enrollees with a SUD diagnosis during their first 6 months of enrollment in a managed care plan in 2015-2017. A series of linear regression models quantified service disparities across race/ethnicity for 5 outcome indicators: treatment engagement, receipt of psychosocial treatment, follow-up after withdrawal, rapid readmission, and treatment continuation. We assessed the degree to which plan membership and place of residence contributed to observed disparities.

RESULTS

We found disparities in access to treatment but the magnitude of the disparities in most cases was small. Plan membership and geography of residence explained little of the observed disparities. One exception is geography of residence among Asian Americans, which appears to mediate disparities for 2 of our 5 outcome measures.

CONCLUSIONS

Reallocating enrollees among MMC plans in NYC or evolving trends in group place of residence are unlikely to reduce disparities in treatment for SUD. System-wide reforms are needed to mitigate disparities.

The Opioid Crisis in Black Communities

While much of the social and political attention surrounding the nationwide opioid epidemic has focused on the dramatic increase in overdose deaths among white, middle-class, suburban and rural users, the impact of the epidemic in Black communities has largely been unrecognized. Though rates of opioid use at the national scale are higher for whites than they are for Blacks, rates of increase in opioid deaths have been rising more steeply among Blacks (43%) than whites (22%) over the last five years. Moreover, the rate of opioid overdose deaths among Blacks already exceeds that of whites in several states. The lack of discussion of Black overdose deaths in the national opioid discourse further marginalizes Black people, and is highly consistent with a history of framing the addictions of people of color as deserving of criminal punishment, rather than worthy of medical treatment. This article argues that, because racial inequalities are embedded in American popular and political cultures as well as in medicine, the federal and state governments should develop more culturally targeted programs to benefit Black communities in the opioid crisis. Such programs include the use of faith-based organizations to deliver substance use prevention and treatment services, the inclusion of racial impact assessments in the implementation of drug policy proposals, and the formal consideration of Black people's interaction with the criminal justice system in designing treatment options.

Racial and ethnic differences in opioid agonist treatment for opioid use disorder in a U.S. national sample

BACKGROUND

Opioid Agonist Treatment (OAT) is the standard of care for the treatment of opioid use disorders. However, most people in treatment do not receive OAT. This study evaluated whether there are racial and/or ethnic differences in OAT receipt among adults entering specialty treatment for opioid use disorders in publicly-funded treatment programs across the U.S.

METHODS

Using data from the national Treatment: Episode Data Base, odds of OAT receipt were compared among black, Hispanic and white clients. Mediation analyses were used to explore whether any racial/ethnic differences in OAT receipt were explained by variation in clinical need or by other treatment, sociodemographic, or geographic characteristics. Interaction terms were used to assess whether this association was modified by primary opioid type.

RESULTS

Only 28.7% of clients received OAT. Odds of OAT receipt were significantly higher odds among blacks (OR: 2.27(2.14-2.41)) and Hispanics (OR: 1.98(1.88-2.09)), compared to whites. Differences in clinical need accounted for a substantial portion of this difference (76.79% and 49.74%, respectively). Differences persisted after accounting for other potential explanatory variables (adjusted OR: 1.37 (1.24-1.52); 1.21(1.11-1.32)), but were only evident for primary heroin users (adjusted OR: 1.50 (1.34-1.69); 1.29 (1.17-1.42)) and not other opioid users.

CONCLUSIONS

OAT receipt in treatment programs is low overall and particularly lacking among white heroin users. Differences in OAT receipt cannot be fully explained by differences in clinical need. More research is needed to understand and address barriers that underpin these differences so more patients with opioid use disorder can access evidenced-based treatment.

Substance Use Issues Among the Underserved: United States and International Perspectives

Substance use affects people of all ages, cultures, and socioeconomic levels. Most underserved populations have lower rates of substance use than the general population in a given society, excluding tobacco use. The impact of substance use is more severe, however, in the underserved, with higher rates of incarceration, job loss, morbidity, and mortality. Innovative solutions are being developed to address these differences. Working together, underserved patients with substance use problems can be helped on their journeys toward health and wholeness.

Race/ethnic disparities in the utilization of treatment for drug dependent inmates in U.S. state correctional facilities

BACKGROUND

Research has documented racial and ethnic disparities in utilization, access, continuity, and quality of care for psychiatric disorders including treatment for substance use disorders among those with similar need in the general community. Currently, the extent of racial and ethnic disparities in treatment within U.S. correctional facilities is unknown.

METHODS

This study examines race/ethnic disparities in treatment for drug dependent inmates using the 2004 Survey of Inmates in State Correctional Facilities. Fixed effects logistic regression is used to analyze treatment outcomes for 5180 inmates housed within 286 prisons. The analysis accounts for differences in background characteristics (i.e., age, gender, marital status, foreign born status, veteran status), socioeconomic characteristics (i.e., education, employment prior to incarceration), mental health (i.e., diagnosis with a serious mental illness), and incarceration experiences (i.e., current conviction, previous incarceration episodes, time served, additional sentencing requirements, external social support, disciplinary violations).

RESULTS

The findings identify a remarkable unmet need among drug dependent inmates in that less than one-half of drug dependent inmates had received any type of treatment in prison at the time of the interview with the most common treatment type being self-help groups. Compared to whites, drug dependent Latino inmates have significantly lower odds of utilizing treatment, yet there are no significant black--white disparities found.

CONCLUSION

The current study suggests that treatment for drug dependent inmates needs to be expanded to include clinically or medically based treatment since the failure to address addictions in the criminal legal system has been identified as the single most significant reason for rearrest and recidivism once released.

Racial/Ethnic Differences in Recent Drug Detoxification Enrollment and the Role of Discrimination and Neighborhood Factors

Drug detoxification and long-term drug treatment utilization is lower for drug-dependent minorities than Whites. Log-binomial regression was used to assess discrimination and neighborhood-level factors on past 6-month drug treatment utilization among 638 New York City (NYC) drug users between 2006 and 2009. Drug-use discrimination was positively associated with detoxification and long-term treatment. Participants in higher concentrated Black neighborhoods were less likely to attend long-term treatment. Significantly fewer Blacks versus Whites and Hispanics reported drug-use discrimination, which may systematically filter drug users into treatment. More research is needed to understand social forms of discrimination and drug treatment.

Disparities in Latino substance use, service use, and treatment: implications for culturally and evidence-based interventions under health care reform

BACKGROUND

The goal of this systematic literature review was to enhance understanding of substance use, service use, and treatment among Latino subgroups to improve access to care and treatment outcomes in an era of health care reform.

METHODS

The authors used 13 electronic databases and manually searched the literature from January 1, 1978, to May 30, 2013. One hundred (69%) of 145 primary research articles met the inclusion criteria. Two blinded, independent reviewers scored each article. Consensus discussions and a content expert reconciled discrepancies.

RESULTS

Current rates of alcohol and substance abuse among Latinos are comparable to or surpass other U.S. ethnic groups. Disparities in access and quality of care are evident between Latinos and other ethnic groups. As a heterogeneous group, Latinos vary by geographic region in terms of substance of choice and their cultural identity takes precedence over general ethnic identity as a likely determinant of substance abuse behaviors. There is growing research interest in systems influencing treatment access and adherence among racial/ethnic and gender minority groups. However, studies on Latinos' service use and immediate treatment outcomes have been both limited in number and inconsistent in findings.

CONCLUSIONS

This review identified human capital, quality of care, and access to culturally responsive care as key strategies to eliminate disparities in health and treatment quality. Implications are discussed, including the need for effectiveness studies on Latinos served by systems of care that, under health care reform, are seeking to maximize resources, improve outcomes, and reduce variation in quality of care.

Community context and healthcare quality: the impact of community resources on licensing and accreditation of substance abuse treatment agencies

This study examines variation in healthcare quality among substance abuse treatment agencies. Using an organizations framework, the authors predict that resource advantages benefit certain types of healthcare organizations, especially those located in affluent communities. As a result, levels of licensing and accreditation of substance abuse treatment agencies will differ across United States counties. The authors model these resources at both the organizational and community levels in an effort to understand the variability of licensing and accreditation between agencies and their local contexts. In multivariate models, the findings confirm that organizational characteristics such as private ownership (compared to public ownership), managed care contracts, inpatient and residential programs (compared to outpatient settings), as well as socioeconomic, racial/ethnic, and healthcare system advantage promote higher levels of licensing and accreditation. Public ownership and outpatient settings, as well as socioeconomic, racial/ethnic, and healthcare system disadvantage, are associated with lower levels of licensing and accreditation.

Racial/ethnic minority and low-income hotspots and their geographic proximity to integrated care providers

Background

The high prevalence of mental health issues among clients attending substance abuse treatment (SAT) has pressured treatment providers to develop integrated substance abuse and mental health care. However, access to integrated care is limited to certain communities. Racial and ethnic minority and low-income communities may not have access to needed integrated care in large urban areas. Because the main principle of health care reform is to expand health insurance to low-income individuals to improve access to care and reduce health disparities among minorities, it is necessary to understand the extent to which integrated care is geographically accessible in minority and low-income communities.

Methods

National Survey of Substance Abuse Treatment Services data from 2010 were used to examine geographic availability of facilities offering integration of mental health services in SAT programs in Los Angeles County, California. Using geographic information systems (GIS), service areas were constructed for each facility (N = 402 facilities; 104 offering integrated services) representing the surrounding area within a 10-minute drive. Spatial autocorrelation analyses were used to derive hot spots (or clusters) of census tracts with high concentrations of African American, Asian, Latino, and low-income households. Access to integrated care was reflected by the hot spot coverage of each facility, i.e., the proportion of its service area that overlapped with each type of hot spot.

Results

GIS analysis suggested that ethnic and low-income communities have limited access to facilities offering integrated care; only one fourth of SAT providers offered integrated care. Regression analysis showed facilities whose service areas overlapped more with Latino hot spots were less likely to offer integrated care, as well as a potential interaction effect between Latino and high-poverty hot spots.

Conclusion

Despite significant pressure to enhance access to integrated services, ethnic and racial minority communities are disadvantaged in terms of proximity to this type of care. These findings can inform health care policy to increase geographic access to integrated care for the increasing number of clients with public health insurance.

A spatial analysis of community disadvantage and access to healthcare services in the U.S

Ongoing socioeconomic and racial and ethnic gaps in access to healthcare make it vital to examine the relationship between characteristics of communities and their impact on the availability of healthcare services. This study investigates how community-based resource constraints influence the provision of healthcare services in the United States. Drawing on several theoretical frameworks including research in the spatial distribution of healthcare, we compile data on 3141 U.S. counties in order to investigate the argument that gaps in the provision of substance abuse treatment are a function of resource constraints experienced by disadvantaged communities. Our principal aim is to demonstrate that socioeconomic privation, racial and ethnic isolation and limited healthcare infrastructure constrain the provision of substance abuse treatment services. Since prior research shows spatial clustering of socioeconomic privation, racial and ethnic isolation, and healthcare resources, we explicitly model the spatial dimensions of community-based resource disadvantage. Central findings support our chief expectations: counties with greater socioeconomic privation and diminished healthcare infrastructure experienced limited access to substance abuse treatment. Moreover, treatment clusters themselves were significantly related to socioeconomic privation and diminished healthcare infrastructure. Counties with a higher proportion of racial and ethnic minority members, however, did not experience less access to substance abuse treatment, with one exception, although post hoc analyses showed poverty had a moderating effect on race and ethnicity. Study limitations and implications for the organization of treatment resources are discussed.

The impact of buprenorphine on treatment of opioid dependence in a Medicaid population: recent service utilization trends in the use of buprenorphine and methadone

BACKGROUND

Buprenorphine provides an important option for individuals with opioid dependence who are unwilling or unable to attend a licensed methadone opioid agonist treatment program to receive opioid agonist therapy (OAT). Little empirical information is available, however, about the extent to which buprenorphine has increased the percentage of opioid dependent individuals receiving OAT, nor to what extent buprenorphine is being used in office based settings.

METHODS

Using administrative data from the largest Medicaid managed behavioral health organization in a large mid-Atlantic state, we used multivariate regression to examine rates and predictors of opioid agonist use and treatment setting for 14,386 new opioid dependence treatment episodes during 2007-2009.

RESULTS

Despite an increase in the use of buprenorphine, the percentage of new treatment episodes involving OAT is unchanged due to a decrease in the percentage of episodes involving methadone. Use of buprenorphine was significantly more common in rural communities, and 64% of buprenorphine use was in office-based settings.

CONCLUSION

Buprenorphine use has increased in recent years, with the greatest use in rural communities and in office based settings. However, the percentage of new opioid dependence treatment episodes involving an opioid agonist is unchanged, suggesting the need for further efforts to increase buprenorphine use among urban populations.

Cultural competence in outpatient substance abuse treatment: measurement and relationship to wait time and retention

BACKGROUND

Culturally competent practice is broadly acknowledged to be an important strategy to increase the quality of services for racial/ethnic minorities in substance abuse treatment. However, few empirically derived measures of organizational cultural competence exist, and relatively little is known about how these measures affect treatment outcomes.

METHOD

Using a nationally representative sample of outpatient substance abuse treatment (OSAT) programs, this study used item response theory to create two measures of cultural competence-organizational practices and managers' culturally sensitive beliefs-and examined their relationship to client wait time and retention using Poisson regression modeling.

RESULTS

The most common and precisely measured organizational practices reported by OSAT managers included matching providers and clients based on language/dialect; offering cross-cultural training; and fostering connections with community and faith-based organizations connected to racial and ethnic minority groups. The most culturally sensitive belief among OSAT managers was support for language/dialect matching for racial and ethnic minority clients. Results of regression modeling indicate that organizational practices were not related to either outcome. However, managers' culturally sensitive beliefs were negatively associated with average wait time (p<0.05), and positively associated with average retention (p<0.01).

CONCLUSIONS

Managers' culturally sensitive beliefs-considered to be influential for effective implementation of culturally competent practices-may be particularly relevant in influencing wait time and retention in OSAT organizations that treat Latinos and African American clients.

Racial and ethnic differences in substance abuse service needs, utilization, and outcomes in California

OBJECTIVE

This study examined differences in service needs and treatment utilization, retention, and outcomes between African-American, Hispanic, and white substance abusers in community-based treatment programs.

METHODS

Data were collected from 2,401 African Americans, 3,222 Hispanics, and 7,980 whites who were admitted to 43 drug treatment programs across California from 2000 to 2001. The Addiction Severity Index (ASI) was administered at intake to assess clients' problem severity in a number of domains (alcohol use, drug use, employment, family and social relationships, legal, medical, and psychological), and treatment retention and arrest data were obtained from administrative records. A subsample was followed up at three months to assess service utilization (N=2,145) and again at nine months to readminister the ASI (N=2,566).

RESULTS

All three groups had similar severity levels of drug and legal problems upon treatment entry. Upon entry to treatment, white clients had the highest severity levels of alcohol, family, and psychiatric problems and African Americans had the highest severity levels of employment problems compared with the other two groups. Treatment retention did not differ between the three groups, but whites received a greater number of alcohol treatment services than did African Americans or Hispanics, and African Americans received a greater number of employment services than did Hispanic and white clients. All three groups showed significant improvement in all outcome domains except for medical outcomes. At the nine-month follow-up, whites had worse outcomes in the alcohol domain compared with the other two groups, and whites had worse outcomes in the legal domain compared with Hispanics. Compared with whites, African Americans were significantly less likely to be charged with driving under the influence in the year after treatment admission.

CONCLUSIONS

All three groups improved after treatment, although benefits from treatment can be further enhanced if services underscore different facets of the psychosocial problems of each racial and ethnic group.

Ethnic disparities in accessing treatment for depression and substance use disorders in an integrated health plan

OBJECTIVE

This study examined ethnic differences in accessing treatment for depression and substance use disorders (SUDs) among men and women in a large integrated health plan, and explored factors potentially contributing to health care disparities.

METHODS

Participants were 22,543 members ages 20 to 65 who responded to health surveys in 2002 and 2005. Survey questions were linked to provider-assigned diagnoses, electronic medication, psychiatry, and chemical dependency program records.

RESULTS

Among women diagnosed with depression, Latinas (p < .01) and Asian-Americans (p < .001) were less likely than Whites to fill an antidepressant prescription. Among men diagnosed with depression, African Americans (p < .01) were less likely than Whites to do so. Among women diagnosed with an SUD, African Americans (p < .05) were less likely than Whites to have one or more chemical dependency program visits.

CONCLUSIONS

Results demonstrated ethnic differences in accessing depression and SUD treatment among patients diagnosed with these disorders, which persisted after controlling for education, income, having a regular health care provider and length of health plan enrollment. Findings highlight potential gender differences in ethnic disparities, lower antidepressant utilization among Asian Americans, and the effects of co-occurring disorders in accessing behavioral health care.

Substance abuse detoxification and residential treatment among Medicaid-enrolled adults: rates and duration of subsequent treatment

BACKGROUND

Substance use disorders are chronic disorders with substantial public health significance, yet the treatment provided is often episodic despite ongoing need. Among the more severely ill individuals requiring detoxification or residential treatment, little empirical information is available about rates and predictors of subsequent engagement in necessary subsequent treatment.

METHODS

Using administrative data from the largest Medicaid managed behavioral health organization in a large mid-Atlantic state, we used multivariate regression to examine rates and predictors of subsequent treatment engagement and retention following new episodes of detoxification or residential substance abuse treatment among 5670 Medicaid-enrolled adults during 2004-2006.

RESULTS

Slightly less than half (49%) of the sample received follow-up care within 30 days of discharge. Rates of follow-up were significantly higher in individuals with a serious mental illness, and significantly lower in African-American individuals, males, individuals with disabilities, and those who received detoxification without residential treatment. The mean duration of follow-up treatment was 84 days, and was longer among individuals with a serious mental illness and Caucasians. Even after controlling for individuals' sociodemographic and clinical characteristics, there was substantial variation in follow-up rates among discharging providers.

CONCLUSION

The relatively low rates of follow-up care and relatively brief duration of treatment for many of those who received such follow-up care are concerning in a population receiving substance abuse detoxification or residential treatment. The markedly lower rates among those receiving detoxification alone without subsequent residential treatment and among those without a comorbid serious mental illness suggest that efforts specifically targeting those individuals may be of particular benefit.

Racial and Ethnic Composition as a Correlate of Medication Availability within Addiction Treatment Organizations

Most analyses of racial and ethnic disparities in healthcare focus on individuals rather than organizations. Healthcare organizations may be one mechanism that produces disparities if the representation of minorities within organizations' patient populations is associated with differential patterns of service delivery. This research considers whether the racial and ethnic composition of addiction treatment centers' caseloads is associated with the likelihood that organizations offer any prescription medications to treat addiction, psychiatric conditions, or pain. Data were collected from 288 publicly-funded substance abuse treatment centers in the US. Logistic regression was used to estimate models of medication availability. The percentage of racial and ethnic minority patients was negatively associated with the odds of medication availability, even after controlling for organizational characteristics and patients' diagnostic characteristics. Future research should continue to investigate how healthcare organizations may produce inequalities in access to high-quality care.

Influence of ownership on access in outpatient substance abuse treatment

Marked changes in ownership and control in substance abuse treatment delivery have garnered the attention of providers and policymakers alike. The proliferation of private for-profit providers and the shift to a delivery system that may be more explicitly influenced by financial incentives are of particular concern for this vulnerable population. This work empirically addresses how treatment unit ownership affected access and retention between 1995 and 2005 in the United States. Regressions show statistically significant associations between unit ownership and both restricted treatment access and shortening of treatment duration for financial reasons. In comparison to private nonprofit and public units, private for-profit units were less likely to provide initial treatment access and reported shortened treatment for a greater percentage of clients unable to pay. Other organization characteristics, such as methadone-maintenance programs and managed care participation, also were associated with limiting treatment accessibility. While this work does not determine the underlying motivation behind access limitations, continued shifts in ownership structure should heighten the attention of policymakers.

Need-service matching in substance abuse treatment: racial/ethnic differences

This study examines the impact of ancillary health and social services matched to client needs in substance abuse treatment for African Americans, Latinos and Whites. The study uses data collected from 1992 to 1997 for the National Treatment Improvement Evaluation Study, a prospective cohort study of substance abuse treatment programs and their clients. The analytic sample consists of 3142 clients (1812 African Americans, 486 Latinos, 844 Whites) from 59 treatment facilities. Results show that racial/ethnic minorities are underserved compared to Whites in the substance abuse service system. Different racial/ethnic groups come into treatment with distinct needs and receive distinct services. Although groups respond differentially to service types, substance abuse counseling and matching services to needs is an effective strategy both for retaining clients in treatment and for reducing post-treatment substance use for African Americans and Whites. Receipt of access services was related to reduced post-treatment substance use for Latinos. Study findings are relevant to planning special services for African Americans and Latinos.

Medicaid managed care for mental health services: the survival of safety net institutions in rural settings

Few accounts document the rural context of mental health safety net institutions (SNIs), especially as they respond to changing public policies. Embedded in wider processes of welfare state restructuring, privatization has transformed state Medicaid systems nationwide. We carried out an ethnographic study in two rural, culturally distinct regions of New Mexico to assess the effects of Medicaid managed care (MMC) and the implications for future reform. After 160 interviews and participant observation at SNIs, we analyzed data through iterative coding procedures. SNIs responded to MMC by nonparticipation, partnering, downsizing, and tapping into alternative funding sources. Numerous barriers impaired access under MMC: service fragmentation, transportation, lack of cultural and linguistic competency, Medicaid enrollment, stigma, and immigration status. By privatizing Medicaid and contracting with for-profit managed care organizations, the state placed additional responsibilities on "disciplined" providers and clients. Managed care models might compromise the rural mental health safety net unless the serious gaps and limitations are addressed in existing services and funding.

Ethnic differences in utilization of drug treatment services and outcomes among Proposition 36 offenders in California

This study examined whether ethnic differences exist in access to care, receipt of services, and associated outcomes of 1,057 offenders participating in California's Proposition 36. Data are based on intake and 3-month follow-up interviews conducted as part of a multisite prospective treatment outcome study. Logistic regressions were conducted to examine ethnicity and other predictors of treatment placement and services intensity. Across ethnic groups, services intensity in several domains was inadequately matched to need, and few services besides substance abuse treatment were provided. Blacks and Hispanics received alcohol and employment services that were not commensurate with their greater need. Although Blacks were more likely to be placed in residential programs, their employment status worsened from intake to follow-up. There were few other ethnic differences in outcomes. Assessing and eliminating ethnic-associated differences in health service delivery, even as moderate as our findings revealed, may improve program processes and outcomes.

Racial and ethnic differences in receipt of primary care services between medicaid fee-for-service and managed care plans

We used a cross-sectional, population-based sample of Medicaid beneficiaries aged 18-64 to determine whether managed care enrollment was associated with reduced racial/ethnic disparities in self-reported access to primary care services compared with fee-for-service. Managed care beneficiaries reported greater access in each racial/ethnic category and for each outcome than did fee-for-service beneficiaries, although associations were not always statistically significant. Racial/ethnic minorities enrolled in managed care plans reported as much benefit from managed care enrollment as did whites. Within Medicaid, interventions aimed at the health insurance delivery model can facilitate increased access to primary care services without enhancing racial/ethnic disparities.

Windows of opportunity: fundamental concepts for understanding alcohol-related disparities experienced by young Blacks in the United States

This paper presents a theoretical framework for conceptualizing alcohol-related disparities experienced by young Blacks in the United States. The framework highlights areas of risk and opportunity as they relate to the development of alcohol use and alcohol-related problems. In this paper, life course development theory serves as a guide for identifying a critical period in the development of alcohol-related disparities and it serves to guide the identification of opportunities to prevent or attenuate this health outcome. We also highlight concepts from ecosocial theory, resilience theory, and prevention science that advance our understanding of risk and protective factors for the social problems that young Blacks experience related to alcohol use. We conclude with suggestions for designing studies that range from etiology to preventive interventions. We also recommend methodologies that allow for more nuanced understandings of the etiology and prevention of alcohol use and alcohol-related problems experienced by young Blacks than have been available to date.

Outpatient mental health utilization among commercially insured individuals: in- and out-of-network care

OBJECTIVE

This study examined the rates and correlates of out-of-network outpatient mental health specialty care.

RESEARCH DESIGN

Using administrative data from a large insurer, we examine the frequency of out-of-network utilization, analyze demographic and clinical characteristics of individuals receiving out-of-network care, and examine the types of service provided out-of-network.

RESULTS

Out-of-network outpatient mental health care was received by 15.4% of adults who used outpatient mental health services, with 11.8% of adult outpatient mental health users receiving only out-of-network care and 3.6% receiving both in-network and out-of-network care. Out-of-network users received significantly more outpatient mental health care than individuals receiving only in-network mental health care. Rates of out-of-network psychotherapy services were substantially greater than for other commonly provided mental health services.

CONCLUSION

A significant number of patients covered under this insurer received their outpatient mental health care out-of-network. This is most pronounced for individuals receiving psychotherapy. Further information is needed to improve our understanding of who seeks care from out-of-network providers and why as well as the effect of such care on clinical outcomes.