Ensuring access to high-quality substance use disorder treatment for Medicaid enrollees: A qualitative study of diverse stakeholders' perspectives

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.

Performance Metrics of Substance Use Disorder Care Among Medicaid Enrollees in New York, New York

Importance

There is limited evaluation of the performance of Medicaid managed care (MMC) private plans in covering substance use disorder (SUD) treatment.

Objective

To compare the performance of MMC plans across 19 indicators of access, quality, and outcomes of SUD treatment.

Design Setting and Participants

This cross-sectional study used administrative claims and mandatory assignment to plans of up to 159 016 adult Medicaid recipients residing in 1 of the 5 counties (boroughs) of New York, New York, from January 2009 to December 2017 to identify differences in SUD treatment access, patterns, and outcomes among different types of MMC plans. Data from the latest years were received from the New York State Department of Health in October 2019, and analysis began soon thereafter. Approximately 17% did not make an active choice of plan, and a subset of these (approximately 4%) can be regarded as randomly assigned.

Exposures

Plan assignment.

Main Outcomes and Measures

Percentage of the enrollees achieving performance measures across 19 indicators of access, process, and outcomes of SUD treatment.

Results

Medicaid claims data from 159 016 adults (mean [SD] age, 35.9 [12.7] years; 74 261 women [46.7%]; 8746 [5.5%] Asian, 73 783 [46.4%] Black, and 40 549 [25.5%] White individuals) who were auto assigned to an MMC plan were analyzed. Consistent with national patterns, all plans achieved less than 50% (range, 0%-62.1%) on most performance measures. Across all plans, there were low levels of treatment engagement for alcohol (range, 0%-0.4%) and tobacco treatment (range, 0.8%-7.2%), except for engagement for opioid disorder treatment (range, 41.5%-61.4%). For access measures, 4 of the 9 plans performed significantly higher than the mean on recognition of an SUD diagnosis, any service use for the first time, and tobacco use screening. Of the process measures, total monthly expenditures on SUD treatment was the only measure for which plans differed significantly from the mean. Outcome measures differed little across plans.

Conclusions and Relevance

The results of this cross-sectional study suggest the need for progress in engaging patients in SUD treatment and improvement in the low performance of SUD care and limited variation in MMC plans in New York, New York. Improvement in the overall performance of SUD treatment in Medicaid potentially depends on general program improvements, not moving recipients among plans.