Medicaid coverage and access to publicly funded opiate treatment

The Association of State Opioid Misuse Prevention Policies With Patient- and Provider-Related Outcomes: A Scoping Review

Policy Points This scoping review reveals a growing literature on the effects of certain state opioid misuse prevention policies, but persistent gaps in evidence on other prevalent state policies remain. Policymakers interested in reducing the volume and dosage of opioids prescribed and dispensed can consider adopting robust prescription drug monitoring programs with mandatory access provisions and drug supply management policies, such as prior authorization policies for high-risk prescription opioids. Further research should concentrate on potential unintended consequences of opioid misuse prevention policies, differential policy effects across populations, interventions that have not received sufficient evaluation (eg, Good Samaritan laws, naloxone access laws), and patient-related outcomes.

CONTEXT

In the midst of an opioid crisis in the United States, an influx of state opioid misuse prevention policies has provided new opportunities to generate evidence of policy effectiveness that can inform policy decisions. We conducted a scoping review to synthesize the available evidence on the effectiveness of US state interventions to improve patient and provider outcomes related to opioid misuse and addiction.

METHODS

We searched six online databases to identify evaluations of state opioid policies. Eligible studies examined legislative and administrative policy interventions that evaluated (a) prescribing and dispensing, (b) patient behavior, or (c) patient health.

FINDINGS

Seventy-one articles met our inclusion criteria, including 41 studies published between 2016 and 2018. These articles evaluated nine types of state policies targeting opioid misuse. While prescription drug monitoring programs (PDMPs) have received considerable attention in the literature, far fewer studies addressed other types of state policy. Overall, evidence quality is very low for the majority of policies due to a small number of evaluations. Of interventions that have been the subject of considerable research, promising means of reducing the volume and dosages of opioids prescribed and dispensed include drug supply management policies and robust PDMPs. Due to low study number and quality, evidence is insufficient to draw conclusions regarding interventions targeting patient behavior and health outcomes, including naloxone access laws and Good Samaritan laws.

CONCLUSIONS

Recent research has improved the evidence base on several state interventions targeting opioid misuse. Specifically, moderate evidence suggests that drug supply management policies and robust PDMPs reduce opioid prescribing. Despite the increase in rigorous evaluations, evidence remains limited for the majority of policies, particularly those targeting patient health-related outcomes.

State variation in opioid treatment policies and opioid-related hospital readmissions

BACKGROUND

State policy approaches designed to provide opioid treatment options have received significant attention in addressing the opioid epidemic in the United States. In particular, expanded availability of naloxone to reverse overdose, Good Samaritan laws intended to protect individuals who attempt to provide or obtain emergency services for someone experiencing an opioid overdose, and expanded coverage of medication-assisted treatment (MAT) for individuals with opioid abuse or dependence may help curtail hospital readmissions from opioids. The objective of this retrospective cohort study was to evaluate the association between the presence of state opioid treatment policies-naloxone standing orders, Good Samaritan laws, and Medicaid medication-assisted treatment (MAT) coverage-and opioid-related hospital readmissions.

METHODS

We used 2013-2015 hospital inpatient discharge data from 13 states from the Agency for Healthcare Research and Quality Healthcare Cost and Utilization Project. We examined the relationship between state opioid treatment policies and 90-day opioid-related readmissions after a stay involving an opioid diagnosis.

RESULTS

Our sample included 383,334 opioid-related index hospitalizations. Patients treated in states with naloxone standing-order policies at the time of the index stay had higher adjusted odds of an opioid-related readmission than did those treated in states without such policies; however, this relationship was not present in states with Good Samaritan laws. Medicaid methadone coverage was associated with higher odds of readmission among all insurance groups except Medicaid. Medicaid MAT coverage generosity was associated with higher odds of readmission among the Medicaid group but lower odds of readmission among the Medicare and privately insured groups. More comprehensive Medicaid coverage of substance use disorder treatment and a greater number of opioid treatment programs were associated with lower odds of readmission.

CONCLUSIONS

Differences in index hospitalization rates suggest that states with opioid treatment policies had a higher level of need for opioid-related intervention, which also may account for higher rates of readmission. More research is needed to understand how these policies can be most effective in influencing acute care use.

State variations in Medicaid enrollment and utilization of substance use services: Results from a National Longitudinal Study

Medicaid enrollment varies considerably among states. This study examined the association of Medicaid enrollment with the use of substance health services in the longitudinal National Epidemiologic Survey on Alcohol and Related Conditions of 2001-2005. Instrumental variable methods were used to assess endogeneity of individual-level Medicaid enrollment using state-level data as instruments. Compared to the uninsured, Medicaid covered adults were more likely to use substance use disorder treatment services over the next three years. States that have opted to expand Medicaid enrollment under the Affordable Care Act will likely experience further increases in the use of these service over the coming years.

Survey Highlights Differences In Medicaid Coverage For Substance Use Treatment And Opioid Use Disorder Medications

The Affordable Care Act requires state Medicaid programs to cover substance use disorder treatment for their Medicaid expansion population but allows states to decide which individual services are reimbursable. To examine how states have defined substance use disorder benefit packages, we used data from 2013-14 that we collected as part of an ongoing nationwide survey of state Medicaid programs. Our findings highlight important state-level differences in coverage for substance use disorder treatment and opioid use disorder medications across the United States. Many states did not cover all levels of care required for effective substance use disorder treatment or medications required for effective opioid use disorder treatment as defined by American Society of Addiction Medicine criteria, which could result in lack of access to needed services for low-income populations.

Policies related to opioid agonist therapy for opioid use disorders: The evolution of state policies from 2004 to 2013

BACKGROUND

State Medicaid policies play an important role in Medicaid enrollees' access to and use of opioid agonists, such as methadone and buprenorphine, in the treatment of opioid use disorders. Little information is available, however, regarding the evolution of state policies facilitating or hindering access to opioid agonists among Medicaid enrollees.

METHODS

During 2013-2014, we surveyed state Medicaid officials and other designated state substance abuse treatment specialists about their state's recent history of Medicaid coverage and policies pertaining to methadone and buprenorphine. We describe the evolution of such coverage and policies and present an overview of the Medicaid policy environment with respect to opioid agonist therapy from 2004 to 2013.

RESULTS

Among our sample of 45 states with information on buprenorphine and methadone coverage, we found a gradual trend toward adoption of coverage for opioid agonist therapies in state Medicaid agencies. In 2013, only 11% of states in our sample (n = 5) had Medicaid policies that excluded coverage for methadone and buprenorphine, whereas 71% (n = 32) had adopted or maintained policies to cover both buprenorphine and methadone among Medicaid enrollees. We also noted an increase in policies over the time period that may have hindered access to buprenorphine and/or methadone.

CONCLUSIONS

There appears to be a trend for states to enact policies increasing Medicaid coverage of opioid agonist therapies, while in recent years also enacting policies, such as prior authorization requirements, that potentially serve as barriers to opioid agonist therapy utilization. Greater empirical information about the potential benefits and potential unintended consequences of such policies can provide policymakers and others with a more informed understanding of their policy decisions.

Factors related to Medicaid payment acceptance at outpatient substance abuse treatment programs

OBJECTIVE

To examine factors associated with Medicaid acceptance for substance abuse (SA) services by outpatient SA treatment programs.

DATA SOURCES

Secondary analysis of 2003-2006 National Survey of Substance Abuse Treatment Services data combined with state Medicaid policy and usage measures and other publicly available data.

STUDY DESIGN

We used cross-sectional analyses, including state fixed effects, to assess relationships between SA treatment program Medicaid acceptance and (1) program-level factors, (2) county-level sociodemographics and treatment program density, and (3) state-level population characteristics, SA treatment-related factors, and Medicaid policy and usage.

DATA EXTRACTION METHODS

State Medicaid policy data were compiled based on reviews of state Medicaid-related statutes/regulations and Medicaid plans. Other data were publicly available. Principal Findings. Medicaid acceptance was significantly higher for programs: (a) that were publicly funded and in states with Medicaid policy allowing SA treatment coverage; (b) with accreditation/licensure and nonprofit/government ownership, as well as mental- and general-health focused programs; and (c) in counties with lower household income.

CONCLUSIONS

SA treatment program Medicaid acceptance related to program-, county, and state-level factors. The data suggest the importance of state policy and licensure/accreditation requirements in increasing SA program Medicaid access.

Impact of policy changes on emergency department use by Medicaid enrollees in Oregon

OBJECTIVE

In 2003, Oregon's Medicaid expansion program, the Oregon Health Plan (OHP), implemented premiums and copayments and eliminated outpatient behavioral health services. We ascertained whether these changes, including $50 copayments for emergency department (ED) visits, affected ED use.

METHODS

This study used statewide administrative data on 414,009 adult OHP enrollees to compare ED utilization rates (adjusted for patient characteristics) in 3 time periods: (1) before the cutbacks, (2) after the cutbacks, and (3) after partial restoration of benefits. We examined overall ED visits and several subsets of ED visits: visits requiring hospital admission, injury-related, drug-related, alcohol-related, and other psychiatric visits. Because the policy changes affected only the expansion program (OHP Standard), we ascertained the impact of these changes compared with a control group of categorically eligible Medicaid enrollees (OHP Plus).

RESULTS

Compared with the control group, case-mix-adjusted ED utilization rates fell 18% among OHP Standard enrollees after the cutbacks. The rate of ED visits leading to hospitalization fell 24%. Injury-related visits and psychiatric visits excluding chemical dependency exhibited a similar pattern to overall ED visits. Drug-related ED visits increased 32% in the control group, perhaps reflecting the closure of drug treatment programs after the cutbacks reduced their revenue.

CONCLUSION

The policy changes were followed by a substantial reduction in ED use. That ED visits requiring hospital admission fell to about the same extent as overall ED use suggests that OHP enrollees may have been discouraged from using EDs for emergencies as well as less-serious problems.

Medicaid coverage, methadone maintenance, and felony arrests: outcomes of opiate treatment in two states

A modest number of clinics in Oregon and Washington provide MMT maintenance treatment (MMT) services. More than 10,000 clients in each state were followed for 3 years after an initial admission for opiate use between 1993 and 2000. Medicaid clients in both states had far greater access to MMT than their non-Medicaid counterparts, controlling for differences in client characteristics using propensity scores. Months in MMT were associated with much lower arrest rates than time not in treatment, but unexpectedly this was only true for clients participating in MMT for many months. Despite differences in the treatment systems for opiate addiction in these two states observed in previous studies, the current findings generalized across both states.

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.

Using administrative data for longitudinal substance abuse research

The utilization of administrative data in substance abuse research has become more widespread than ever. This selective review synthesizes recent extant research from 31 articles to consider what has been learned from using administrative data to conduct longitudinal substance abuse research in four overlapping areas: (1) service access and utilization, (2) underrepresented populations, (3) treatment outcomes, and (4) cost analysis. Despite several notable limitations, administrative data contribute valuable information, particularly in the investigation of service system interactions and outcomes among substance abusers as they unfold and influence each other over the long term. This critical assessment of the advantages and disadvantages of using existing administrative data within a longitudinal framework should stimulate innovative thinking regarding future applications of administrative data for longitudinal substance abuse research purposes.

Effect of eliminating behavioral health benefits for selected medicaid enrollees

OBJECTIVE

To determine the extent to which the elimination of behavioral health benefits for selected beneficiaries of Oregon's Medicaid program affected general medical expenditures among enrollees using outpatient mental health and substance abuse treatment services.

DATA SOURCE/STUDY SETTING

Twelve months of claims before and 12 months following a 2003 policy change, which included the elimination of the behavioral health benefit for selected Oregon Medicaid enrollees.

STUDY DESIGN

We use a difference-in-differences approach to estimate the change in general medical expenditures following the 2003 policy change. We compare two methodological approaches: regression with propensity score weighting; and one-to-one covariate matching.

PRINCIPAL FINDINGS

Enrollees who had accessed the substance abuse treatment benefit demonstrated substantial and statistically significant increases in expenditures. Individuals who accessed the outpatient mental health benefit demonstrated a decrease or no change in expenditures, depending on model specification.

CONCLUSIONS

Elimination of the substance abuse benefit led to increased medical expenditures, although this offset was still smaller than the total cost of the benefit. In contrast, individuals who accessed the outpatient mental health benefit did not exhibit a similar increase, although these individuals did not include a portion of the Medicaid population with severe mental illnesses.

Implications of Medicaid coverage in a program for Latino substance users

BACKGROUND

This cross-sectional study explored baseline differences between Medicaid covered and uninsured clients (n=368) in the Project La Voz, a community outreach program targeting Latino substance users.

METHODS

Independent variables included client demographics, health status and health service use; the dependent variable was Medicaid coverage vs. uninsured. Bi-variate analyses and three binomial logistic regression models were conducted.

RESULTS

The first logistic regression model examining client characteristics indicated that La Voz enrollees with Medicaid coverage were more likely to be women, reside in stable housing, and report poor health status. Employment and educational status were not significantly associated with having Medicaid. A second model, examining the association between health care utilization in the past 30 days and Medicaid coverage, indicated that LaVoz enrollees with Medicaid were significantly more likely to have entered substance use treatment. In the third model, client characteristics and health care use were examined in one model; all variables remained significant except for gender. IMPLICATIONS FOR PROGRAM PLANNING: Massachusetts recent health care reform efforts include substance abuse treatment benefits through Medicaid. Specific strategies are needed to ensure that Latinos substance abusers, particularly those who are homeless, gain Medicaid coverage and then have access to needed services.