1
|
Peterson LA, Andrews CM, Abraham AJ, Westlake MA, Grogan CM. Most States Allow Medicaid Managed Care Plans Discretion To Restrict Substance Use Disorder Treatment Benefits. Health Aff (Millwood) 2024; 43:1038-1046. [PMID: 38950296 DOI: 10.1377/hlthaff.2023.01023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/03/2024]
Abstract
Managed care plans, which contract with states to cover three-quarters of Medicaid enrollees, play a crucial role in addressing the drug epidemic in the United States. However, substance use disorder benefits vary across Medicaid managed care plans, and it is unclear what role states play in regulating their activities. To address this question, we surveyed thirty-three states and Washington, D.C., regarding their substance use disorder treatment coverage and utilization management requirements for Medicaid managed care plans in 2021. Most states mandated coverage of common forms of substance use disorder treatment and prohibited annual maximums and enrollee cost sharing in managed care. Fewer than one-third of states forbade managed care plans from imposing prior authorization for each treatment service. For most treatment medications, fewer than two-thirds of states prohibited prior authorization, drug testing, "fail first," or psychosocial therapy requirements in managed care. Our findings suggest that many states give managed care plans broad discretion to impose requirements on covered substance use disorder treatments, which may affect access to lifesaving care.
Collapse
Affiliation(s)
| | - Christina M Andrews
- Christina M. Andrews, University of South Carolina, Columbia, South Carolina
| | | | | | | |
Collapse
|
2
|
Shrira I, Foster JD. Elevated drug overdose mortality among Americans who visit Florida, 2003-2020. Inj Prev 2024; 30:183-187. [PMID: 38307716 DOI: 10.1136/ip-2023-045053] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2023] [Accepted: 12/21/2023] [Indexed: 02/04/2024]
Abstract
OBJECTIVE Florida state has played a conspicuous role in the current U.S. drug epidemic. Reports suggest that even non-Florida residents may suffer excessive overdose fatalities while visiting the state, possibly in connection to two sets of events: (1) the overprescribing of controlled substances, and more recently, (2) the exploitation of patients' insurance benefits by unscrupulous operators of substance use treatment facilities in Florida. To date, however, no research has examined the overdose fatalities of non-Florida residents inside Florida. METHODS Death certificate data were used to calculate proportionate mortality ratios for overdoses among Florida residents and visitors. Deaths occurring in the rest of the USA were used as reference populations. RESULTS Between 2003 and 2020, overdose mortality was slightly elevated for Florida residents within their home counties (106.7 (95% CI 105.8 to 107.5)) and in other Florida counties (113.0 (95% CI 110.0 to 116.0)). Significantly, this mortality was much higher among out-of-state visitors in Florida (163.1 (95% CI 157.5 to 168.8)). When analysed by year, greater overdose mortality among visitors coincided with years when drug prescribing in Florida was rampant, and with the advent of expanded insurance coverage for substance use treatment. During this more recent period (since 2014), overdose mortality was exceptionally high for out-of-state visitors in Palm Beach County, where reports of malpractice in the Florida treatment industry have been concentrated. CONCLUSIONS Overdose mortality was disproportionately high among out-of-state visitors in Florida. The results suggest that the regulatory policies in Florida may be implicated in drug-related casualties of people who live in other parts of the USA.
Collapse
Affiliation(s)
- Ilan Shrira
- Department of Psychology, Pennsylvania State University, University Park, Pennsylvania, USA
| | - Joshua D Foster
- Department of Psychology, University of South Alabama, Mobile, Alabama, USA
| |
Collapse
|
3
|
Marks SJ, Pham H, McCray N, Palazzolo J, Harrell A, Lowe J, Bachireddy C, Guerra L, Cunningham PJ, Barnes AJ. Patient experiences with outpatient opioid use disorder treatment before and during COVID-19: results from a survey of Medicaid members. THE AMERICAN JOURNAL OF DRUG AND ALCOHOL ABUSE 2024; 50:357-370. [PMID: 38759212 DOI: 10.1080/00952990.2024.2328543] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/04/2023] [Revised: 02/20/2024] [Accepted: 03/05/2024] [Indexed: 05/19/2024]
Abstract
Background: Payers are increasingly interested in quality improvement for opioid use disorder (OUD) treatment, including incorporating patient experiences. Medicaid is the largest payer for OUD treatment, yet we know little about the treatment benefits Medicaid members report, how these vary across members, or changed with the COVID-19 pandemic.Objective: To examine Medicaid members' report of outpatient treatment benefits, employment, and housing outcomes before and during the pandemic.Methods: A representative sample of 1,032 Virginia Medicaid members (52% women) receiving OUD treatment completed a survey of treatment benefits, health status and social needs. A reported treatment benefit index was created based on seven self-reported items. Multivariable linear regression models, pooled and stratified by time (pre-COVID-19/COVID-19), assessed member characteristics associated with reported treatment benefit, employment and housing outcomes.Results: Members reported strong treatment benefit (mean: 21.8 [SD: 5.9] out of 28 points) and improvements in employment (2.4 [1.3] out of 5) and housing (2.8 [1.2] out of 5). After adjustment, mental distress (regression coefficient: -3.00 [95% CI:-3.97;-2.03]), polysubstance use (-1.25 [-1.99;-0.51]), and food insecurity (-1.00 [-1.71;-0.29]), were associated with decreased benefits from treatment. During COVID-19, justice-involved individuals reported decreased benefits (-2.17 [-3.54; -0.80]) compared to before the pandemic (-0.09 [-1.4-;1.24] p < .05).Conclusions: Medicaid members receiving outpatient OUD treatment reported positive treatment benefits, and housing and employment outcomes. However, those with comorbid health and social conditions often benefited the least. As payers move toward quality improvement and value-based purchasing initiatives, collecting and integrating patient reported outcomes into quality metrics is critical.
Collapse
Affiliation(s)
- Sarah J Marks
- Department of Health Behavior and Policy, Virginia Commonwealth University, Richmond, VA, USA
- Medical Scientist Training Program, Virginia Commonwealth University, Richmond, VA, USA
| | - Huyen Pham
- Semel Institute for Neuroscience and Human Behavior, University of California Los Angeles, Los Angeles, CA, USA
| | - Neil McCray
- Virginia Department of Medical Assistance Services, Richmond, VA, USA
| | | | - Ashley Harrell
- Virginia Department of Medical Assistance Services, Richmond, VA, USA
| | - Jason Lowe
- Virginia Department of Medical Assistance Services, Richmond, VA, USA
| | | | - Lauren Guerra
- Department of Health Behavior and Policy, Virginia Commonwealth University, Richmond, VA, USA
| | - Peter J Cunningham
- Department of Health Behavior and Policy, Virginia Commonwealth University, Richmond, VA, USA
| | - Andrew J Barnes
- Department of Health Behavior and Policy, Virginia Commonwealth University, Richmond, VA, USA
| |
Collapse
|
4
|
Michener PS, Knee A, Wilson D, Boama-Nyarko E, Friedmann PD. Association of random and observed urine drug screening with long-term retention in opioid treatment programs. Drug Alcohol Depend 2024; 255:111067. [PMID: 38183832 PMCID: PMC10956422 DOI: 10.1016/j.drugalcdep.2023.111067] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/07/2023] [Revised: 12/14/2023] [Accepted: 12/15/2023] [Indexed: 01/08/2024]
Abstract
BACKGROUND In the US, opioid treatment providers (OTPs) have wide latitude to perform urine drug screening (UDS) and discharge clients for positive results. OTP clients have identified randomized and directly observed UDS as potentially stigmatizing, but little research has examined the association between UDS modality and retention in OTPs. METHODS This cross-sectional study uses the 2016-2017 NDATSS wave among OTPs that administered methadone. The exposure was a 4-level variable based on whether OTPs had a high percentage (≥ 90% of clients) who experienced randomized, observed, both, or neither modality of UDS. The outcome was the proportion of clients retained in treatment 1 year or longer (long-term retention). Analyses were conducted using fractional logit regression with survey weighting and presented as percentages and 95% confidence intervals. We also present how policies for involuntary clinic discharge modify these effects. RESULTS 150 OTPs were eligible with a median of 310 clients. 40 (27%) OTPs did not highly utilize either randomized or observed UDS, 22 (15%) only highly utilized observed UDS, 42 (28%) only highly utilized randomized UDS and 46 (31%) utilized both practices on ≥ 90% of clients. Adjusted estimates for long-term retention ranged from 57.7% in OTPs that conducted both randomized and observed UDS on ≥ 90% of clients and 70.4% in OTPs that did not highly utilize these practices. Involuntary discharge may moderate this relationship. CONCLUSION Findings showed an association between high utilization of randomized and observed UDS and decreased long-term retention, suggesting that UDS modality may impact long-term OTP retention.
Collapse
Affiliation(s)
- Pryce S Michener
- Clinical and Population Health Research Program, Graduate School of Biomedical Sciences University of Massachusetts Chan Medical School, 55 N Lake Ave, Worcester, MA 01655, USA.
| | - Alexander Knee
- Dept. of Medicine, UMass Chan Medical School - Baystate, 759 Chestnut St, Springfield, MA 01199, USA; Epidemiology/Biostatistics Research Core - Baystate Medical Center, Office of Research, 3601 Main Street, Third Floor, Springfield, MA 01199, USA
| | - Donna Wilson
- Dept. of Medicine, UMass Chan Medical School - Baystate, 759 Chestnut St, Springfield, MA 01199, USA; Epidemiology/Biostatistics Research Core - Baystate Medical Center, Office of Research, 3601 Main Street, Third Floor, Springfield, MA 01199, USA
| | - Esther Boama-Nyarko
- Clinical and Population Health Research Program, Graduate School of Biomedical Sciences University of Massachusetts Chan Medical School, 55 N Lake Ave, Worcester, MA 01655, USA
| | - Peter D Friedmann
- Dept. of Medicine, UMass Chan Medical School - Baystate, 759 Chestnut St, Springfield, MA 01199, USA
| |
Collapse
|
5
|
Soni A, Bullinger L, Andrews C, Abraham A, Simon K. The Impact of State Medicaid Eligibility and Benefits Policy on Neonatal Abstinence Syndrome Hospitalizations. CONTEMPORARY ECONOMIC POLICY 2024; 42:25-40. [PMID: 38463202 PMCID: PMC10923531 DOI: 10.1111/coep.12623] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/13/2021] [Accepted: 07/28/2023] [Indexed: 03/12/2024]
Abstract
Rates of neonatal abstinence syndrome (NAS) resulting from opioid misuse are rising. However, policies to treat opioid misuse during pregnancy are unclear. We apply a difference-in-differences design to national pediatric discharge records to examine the effects of state Medicaid policies on NAS. Among states in which Medicaid covered two clinically-recommended medications for treating opioid misuse (buprenorphine, methadone), the Affordable Care Act's Medicaid expansion reduced Medicaid-covered NAS hospitalizations. Medicaid expansion did not affect NAS hospitalizations in other expansion states. These findings imply a nuanced relationship between Medicaid policy and NAS that should be considered in addressing opioid misuse among pregnant women.
Collapse
Affiliation(s)
| | | | | | | | - Kosali Simon
- Indiana University and National Bureau of Economic Research
| |
Collapse
|
6
|
Howell BA, Hawks LC, Balasuriya L, Chang VW, Wang EA, Winkelman TNA. Health Insurance and Mental Health Treatment Use Among Adults With Criminal Legal Involvement After Medicaid Expansion. Psychiatr Serv 2023; 74:1019-1026. [PMID: 37016823 PMCID: PMC10939137 DOI: 10.1176/appi.ps.20220171] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 04/06/2023]
Abstract
OBJECTIVE Individuals with criminal legal involvement have high rates of substance use and other mental disorders. Before implementation of the Affordable Care Act's Medicaid expansion, they also had low health insurance coverage. The objective of this study was to assess the impact of Medicaid expansion on health insurance coverage and use of treatment for substance use or other mental disorders in this population. METHODS The authors used restricted data (2010-2017) from the National Survey on Drug Use and Health (NSDUH). Using a difference-in-differences approach, the authors estimated the impact of Medicaid expansion on health insurance coverage and treatment for substance use or other mental disorders among individuals with recent criminal legal involvement. RESULTS The sample consisted of 9,910 NSDUH respondents who were ages 18-64 years, had a household income ≤138% of the federal poverty level, and reported past-year criminal legal involvement. Medicaid expansion was associated with an 18 percentage-point increase in insurance coverage but no change in receipt of substance use treatment among individuals with substance use disorder. Individuals with any other mental illness had a 16 percentage-point increase in insurance coverage but no change in receipt of mental health treatment. CONCLUSIONS Despite a large increase in health insurance coverage among individuals with criminal legal involvement and substance use or other mental disorders, Medicaid expansion was not associated with a significant change in treatment use for these conditions. Insurance access alone appears to be insufficient to increase treatment for substance use or other mental disorders in this population.
Collapse
Affiliation(s)
- Benjamin A Howell
- SEICHE Center for Health and Justice and Section of General Internal Medicine (Howell, Wang) and National Clinician Scholars Program (Balasuriya), Yale School of Medicine, New Haven; Division of General Internal Medicine and Center for Advancing Population Science, Medical College of Wisconsin, Milwaukee (Hawks); Department of Social and Behavioral Sciences, School of Global Public Health, and Department of Population Health, Grossman School of Medicine, New York University, New York City (Chang); Health, Homelessness, and Criminal Justice Lab, Hennepin Healthcare Research Institute, and Division of General Internal Medicine, Department of Medicine, Hennepin Healthcare, Minneapolis (Winkelman)
| | - Laura C Hawks
- SEICHE Center for Health and Justice and Section of General Internal Medicine (Howell, Wang) and National Clinician Scholars Program (Balasuriya), Yale School of Medicine, New Haven; Division of General Internal Medicine and Center for Advancing Population Science, Medical College of Wisconsin, Milwaukee (Hawks); Department of Social and Behavioral Sciences, School of Global Public Health, and Department of Population Health, Grossman School of Medicine, New York University, New York City (Chang); Health, Homelessness, and Criminal Justice Lab, Hennepin Healthcare Research Institute, and Division of General Internal Medicine, Department of Medicine, Hennepin Healthcare, Minneapolis (Winkelman)
| | - Lilanthi Balasuriya
- SEICHE Center for Health and Justice and Section of General Internal Medicine (Howell, Wang) and National Clinician Scholars Program (Balasuriya), Yale School of Medicine, New Haven; Division of General Internal Medicine and Center for Advancing Population Science, Medical College of Wisconsin, Milwaukee (Hawks); Department of Social and Behavioral Sciences, School of Global Public Health, and Department of Population Health, Grossman School of Medicine, New York University, New York City (Chang); Health, Homelessness, and Criminal Justice Lab, Hennepin Healthcare Research Institute, and Division of General Internal Medicine, Department of Medicine, Hennepin Healthcare, Minneapolis (Winkelman)
| | - Virginia W Chang
- SEICHE Center for Health and Justice and Section of General Internal Medicine (Howell, Wang) and National Clinician Scholars Program (Balasuriya), Yale School of Medicine, New Haven; Division of General Internal Medicine and Center for Advancing Population Science, Medical College of Wisconsin, Milwaukee (Hawks); Department of Social and Behavioral Sciences, School of Global Public Health, and Department of Population Health, Grossman School of Medicine, New York University, New York City (Chang); Health, Homelessness, and Criminal Justice Lab, Hennepin Healthcare Research Institute, and Division of General Internal Medicine, Department of Medicine, Hennepin Healthcare, Minneapolis (Winkelman)
| | - Emily A Wang
- SEICHE Center for Health and Justice and Section of General Internal Medicine (Howell, Wang) and National Clinician Scholars Program (Balasuriya), Yale School of Medicine, New Haven; Division of General Internal Medicine and Center for Advancing Population Science, Medical College of Wisconsin, Milwaukee (Hawks); Department of Social and Behavioral Sciences, School of Global Public Health, and Department of Population Health, Grossman School of Medicine, New York University, New York City (Chang); Health, Homelessness, and Criminal Justice Lab, Hennepin Healthcare Research Institute, and Division of General Internal Medicine, Department of Medicine, Hennepin Healthcare, Minneapolis (Winkelman)
| | - Tyler N A Winkelman
- SEICHE Center for Health and Justice and Section of General Internal Medicine (Howell, Wang) and National Clinician Scholars Program (Balasuriya), Yale School of Medicine, New Haven; Division of General Internal Medicine and Center for Advancing Population Science, Medical College of Wisconsin, Milwaukee (Hawks); Department of Social and Behavioral Sciences, School of Global Public Health, and Department of Population Health, Grossman School of Medicine, New York University, New York City (Chang); Health, Homelessness, and Criminal Justice Lab, Hennepin Healthcare Research Institute, and Division of General Internal Medicine, Department of Medicine, Hennepin Healthcare, Minneapolis (Winkelman)
| |
Collapse
|
7
|
Shoulders A, Andrews CM, Westlake MA, Abraham AJ, Grogan CM. Changes in Medicaid Fee-for-Service Benefit Design for Substance Use Disorder Treatment During the Opioid Crisis, 2014 to 2021. JAMA HEALTH FORUM 2023; 4:e232502. [PMID: 37566428 PMCID: PMC10422193 DOI: 10.1001/jamahealthforum.2023.2502] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2023] [Accepted: 06/12/2023] [Indexed: 08/12/2023] Open
Abstract
Importance Medicaid is the largest payer of substance use disorder treatment in the US and plays a key role in responding to the opioid epidemic. However, as recently as 2017, many state Medicaid programs still did not cover the full continuum of clinically recommended care. Objective To determine whether state Medicaid fee-for-service (FFS) programs have expanded coverage and loosened restrictions on access to substance use disorder treatment in recent years. Design, Setting, and Participants In 2014, 2017, and 2021, a survey on coverage for substance use disorder treatment was conducted among state Medicaid programs and the District of Columbia with FFS programs. This survey was completed by Medicaid program directors or knowledgeable staff. Data analysis was performed in 2022. Main Outcomes and Measures The following were calculated for a variety of substance use disorder treatment services (individual and group outpatient, intensive outpatient, short-term and long-term residential, recovery support, inpatient treatment and detoxification, and outpatient detoxification) and medications (methadone, oral and injectable naltrexone, and buprenorphine): (1) the percentage of Medicaid FFS programs covering these services and medications and (2) the percentage of Medicaid FFS programs using utilization management policies, such as copayments, prior authorizations, and annual maximums. Results This study had response rates of 92% in 2014 and 2017 (47 of 51 states) and 90% in 2021 (46 of 51 states). For the 2021 wave, data are reported for the 38 non-managed care organization plan-only states. Between 2017 and 2021, coverage of individual and group outpatient treatment increased to 100% of states, and use of annual maximums for medications decreased to 3% or less (n ≤ 1). However, important gaps in coverage persisted, particularly for more intensive services: 10% of Medicaid FFS programs (n = 4) did not cover intensive outpatient treatment, 13% (n = 5) did not cover short-term residential care, and 33% (n = 13) did not cover long-term residential care. Use of utilization controls, such as copays, prior authorizations, and annual maximums, decreased but continued to be widespread. Conclusions and Relevance In this survey study of state Medicaid FFS programs, increases in coverage and decreases in use of utilization management policies over time were observed for substance use disorder treatment and medications. However, these findings suggest that some states still lag behind and impose barriers to treatment. Future research should work to identify the long-term ramifications of these barriers for patients.
Collapse
Affiliation(s)
- Angela Shoulders
- Department of Economics, Darla Moore School of Business, University of South Carolina, Columbia
| | - Christina M. Andrews
- Department of Health Services Policy and Management, Arnold School of Public Health, University of South Carolina, Columbia
| | - Melissa A. Westlake
- Department of Health Services Policy and Management, Arnold School of Public Health, University of South Carolina, Columbia
| | - Amanda J. Abraham
- Department of Public Administration and Policy, School of Public and International Affairs, University of Georgia, Athens
| | - Colleen M. Grogan
- Center for Health Administration Studies, Crown School of Social Work, Policy, and Practice, The University of Chicago, Chicago, Illinois
| |
Collapse
|
8
|
Busch AB, Kennedy-Hendricks A, Schilling C, Stuart EA, Hollander M, Meiselbach MK, Barry CL, Huskamp HA, Eisenberg MD. Measurement Approaches to Estimating Methadone Continuity in Opioid Use Disorder Care. Med Care 2023; 61:314-320. [PMID: 36917776 PMCID: PMC10377507 DOI: 10.1097/mlr.0000000000001838] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/15/2023]
Abstract
BACKGROUND Long-term treatment with medications for opioid use disorder (OUD), including methadone, is lifesaving. There has been little examination of how to measure methadone continuity in claims data. OBJECTIVES To develop an approach for measuring methadone continuity in claims data, and compare estimates of methadone versus buprenorphine continuity. RESEARCH DESIGN Observational cohort study using de-identified commercial claims from OptumLabs Data Warehouse (January 1, 2017-June 30, 2021). SUBJECTS Individuals diagnosed with OUD, ≥1 methadone or buprenorphine claim and ≥180 days continuous enrollment (N=29,633). MEASURES OUD medication continuity: months with any use, days of continuous use, and proportion of days covered. RESULTS 5.4% (N=1607) of the study cohort had any methadone use. Ninety-seven percent of methadone claims (N=160,537) were from procedure codes specifically used in opioid treatment programs. Place of service and primary diagnosis codes indicated that several methadone procedure codes were not used in outpatient OUD care. Methadone billing patterns indicated that estimating days-supply based solely on dates of service and/or procedure codes would yield inaccurate continuity results and that an approach incorporating the time between service dates was more appropriate. Among those using methadone, mean [s.d.] months with any use, days of continuous use, and proportion of days covered were 4.8 [1.8] months, 79.7 [73.4] days, and 0.64 [0.36]. For buprenorphine, the corresponding continuity estimates were 4.6 [1.9], 80.7 [70.0], and 0.73 [0.35]. CONCLUSIONS Estimating methadone continuity in claims data requires a different approach than that for medications largely delivered by prescription fills, highlighting the importance of consistency and transparency in measuring methadone continuity across studies.
Collapse
Affiliation(s)
- Alisa B. Busch
- Mailstop 226, 115 Mill St., McLean Hospital, Belmont MA 02478
- 180 Longwood Ave, Department of Health Care Policy, Harvard Medical School, Boston, MA 02115
| | - Alene Kennedy-Hendricks
- 624 N. Broadway, Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD 21205
| | - Cameron Schilling
- 624 N. Broadway, Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD 21205
| | - Elizabeth A. Stuart
- 615 N. Wolfe St., Department of Mental Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD 21205
| | - Mara Hollander
- 624 N. Broadway, Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD 21205
| | - Mark K. Meiselbach
- 624 N. Broadway, Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD 21205
| | - Colleen L. Barry
- Cornell Jeb E. Brooks School of Public Policy, 2301G Martha Van Rensselaer Hall, 37 Forest Home Drive, Ithaca, NY 14853
| | - Haiden A. Huskamp
- 180 Longwood Ave, Department of Health Care Policy, Harvard Medical School, Boston, MA 02115
| | - Matthew D. Eisenberg
- 624 N. Broadway, Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD 21205
| |
Collapse
|
9
|
Stewart RE, Cardamone NC, Mandell DS, Kwon N, Kampman KM, Knudsen HK, Tjoa CW, Marcus SC. Not in my treatment center: Leadership's perception of barriers to MOUD adoption. J Subst Abuse Treat 2023; 144:108900. [PMID: 36265323 PMCID: PMC10062425 DOI: 10.1016/j.jsat.2022.108900] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2022] [Revised: 08/04/2022] [Accepted: 10/06/2022] [Indexed: 11/06/2022]
Abstract
INTRODUCTION Despite their well-established effectiveness, medications for opioid use disorder (MOUD) are widely underutilized across the United States. In the context of a large publicly funded behavioral health system, we examined the relationship between a range of implementation barriers and a substance use disorder treatment agency's level of adoption of MOUD. METHODS We surveyed leadership of publicly funded substance use disorder treatment centers in Philadelphia about the significance of barriers to implementing MOUD related to their workforce, organization, funding, regulations, and beliefs about MOUD's efficacy and safety. We queried leaders on the percentage of their patients with opioid use disorder who receive MOUD and examined associations between implementation barriers and MOUD adoption. RESULTS Ratings of regulatory, organizational, or funding barriers of respondents who led high MOUD adopting agencies (N = 20) were indistinguishable from those who led agencies that were low adopting of MOUD (N = 23). In contrast, agency leaders who denied MOUD-belief or workforce barriers were significantly more likely to lead high-MOUD-adopting organizations. CONCLUSIONS These findings suggest that leadership beliefs about MOUD may be a key factor of the organizational decision to adopt and should be a target of implementation efforts to increase direct provision of these medications.
Collapse
Affiliation(s)
- Rebecca E Stewart
- University of Pennsylvania Perelman School of Medicine, 3535 Market St, Philadelphia, PA 19104, United States of America.
| | - Nicholas C Cardamone
- University of Pennsylvania Perelman School of Medicine, 3535 Market St, Philadelphia, PA 19104, United States of America.
| | - David S Mandell
- University of Pennsylvania Perelman School of Medicine, 3535 Market St, Philadelphia, PA 19104, United States of America.
| | - Nayoung Kwon
- University of Pennsylvania Perelman School of Medicine, 3535 Market St, Philadelphia, PA 19104, United States of America
| | - Kyle M Kampman
- University of Pennsylvania Perelman School of Medicine, 3535 Market St, Philadelphia, PA 19104, United States of America.
| | - Hannah K Knudsen
- University of Kentucky College of Medicine, 800 Rose Street MN 150, Lexington, KY 40506, United States of America.
| | - Christopher W Tjoa
- University of Pennsylvania Perelman School of Medicine, 3535 Market St, Philadelphia, PA 19104, United States of America; Community Behavioral Health, 801 Market St, Philadelphia, PA 19107, United States of America.
| | - Steven C Marcus
- University of Pennsylvania School of Policy and Practice, 3701 Locust Walk, Philadelphia, PA 19104, United States of America.
| |
Collapse
|
10
|
Cole ES, Allen L, Austin A, Barnes A, Chang CCH, Clark S, Crane D, Cunningham P, Fry CE, Gordon AJ, Hammerslag L, Idala D, Kennedy S, Kim JY, Krishnan S, Lanier P, Mahakalanda S, Mauk R, McDuffie MJ, Mohamoud S, Talbert J, Tang L, Zivin K, Donohue JM. Outpatient follow-up and use of medications for opioid use disorder after residential treatment among Medicaid enrollees in 10 states. Drug Alcohol Depend 2022; 241:109670. [PMID: 36332591 PMCID: PMC10756712 DOI: 10.1016/j.drugalcdep.2022.109670] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/31/2022] [Revised: 10/04/2022] [Accepted: 10/18/2022] [Indexed: 12/14/2022]
Abstract
BACKGROUND Follow-up after residential treatment is considered best practice in supporting patients with opioid use disorder (OUD) in their recovery. Yet, little is known about rates of follow-up after discharge. The objective of this analysis was to measure rates of follow-up and use of medications for OUD (MOUD) after residential treatment among Medicaid enrollees in 10 states, and to understand the enrollee and episode characteristics that are associated with both outcomes. METHODS Using a distributed research network to analyze Medicaid claims data, we estimated the likelihood of 4 outcomes occurring within 7 and 30 days post-discharge from residential treatment for OUD using multinomial logit regression: no follow-up or MOUD, follow-up visit only, MOUD only, or both follow-up and MOUD. We used meta-analysis techniques to pool state-specific estimates into global estimates. RESULTS We identified 90,639 episodes of residential treatment for OUD for 69,017 enrollees from 2018 to 2019. We found that 62.5% and 46.9% of episodes did not receive any follow-up or MOUD at 7 days and 30 days, respectively. In adjusted analyses, co-occurring mental health conditions, longer lengths of stay, prior receipt of MOUD or behavioral health counseling, and a recent ED visit for OUD were associated with a greater likelihood of receiving follow-up treatment including MOUD after discharge. CONCLUSIONS Forty-seven percent of residential treatment episodes for Medicaid enrollees are not followed by an outpatient visit or MOUD, and thus are not following best practices.
Collapse
Affiliation(s)
- Evan S Cole
- University of Pittsburgh, A616, 130 DeSoto Street, Pittsburgh, PA 15261, USA
| | | | - Anna Austin
- University of North Carolina - Chapel Hill, Chapel Hill, NC, USA
| | | | | | | | | | | | | | | | | | | | | | | | | | - Paul Lanier
- University of North Carolina - Chapel Hill, Chapel Hill, NC, USA
| | | | | | | | | | | | - Lu Tang
- University of Pittsburgh, Pittsburgh, PA, USA
| | - Kara Zivin
- University of Michigan, Ann Arbor, MI, USA
| | | |
Collapse
|
11
|
Abraham AJ, Andrews CM, Harris SJ, Westlake MM, Grogan CM. Coverage and Prior Authorization Policies for Medications for Opioid Use Disorder in Medicaid Managed Care. JAMA HEALTH FORUM 2022; 3:e224001. [PMID: 36331441 PMCID: PMC10157383 DOI: 10.1001/jamahealthforum.2022.4001] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
Importance Medicaid is a key policy lever to improve opioid use disorder treatment, covering approximately 40% of Americans with opioid use disorder. Although approximately 70% of Medicaid beneficiaries are enrolled in comprehensive managed care organization (MCO) plans, little is known about coverage and prior authorization (PA) policies for medications for opioid use disorder (MOUD) in these plans. Objective To compare coverage and PA policies for buprenorphine, methadone, and injectable naltrexone across Medicaid MCO plans and fee-for-service (FFS) programs and across states. Design, Setting, and Participants This cross-sectional study analyzed MOUD data from 266 Medicaid MCO plans and FFS programs in 38 states and the District of Columbia in 2018. Main Outcomes and Measures For each medication, the percentages of MCO plans and FFS programs that covered the medication without PA, covered the medication with PA, and did not cover the medication were calculated, as were the percentages of MCO, FFS, and all (MCO and FFS) beneficiaries who were covered with no PA, covered with PA, and not covered. In addition, MCO plan coverage and PA policies were mapped by state. Analyses were conducted from January 1 through May 31, 2022. Results Coverage and PA policies were compared for MOUD in 266 MCO plans and 39 FFS programs, representing approximately 70 million Medicaid beneficiaries. Overall, FFS programs had more generous MOUD coverage than MCO plans. However, a higher percentage of FFS programs imposed PA for the 3 medications (47.0%) than did MCOs (35.9%). Furthermore, although most Medicaid beneficiaries were enrolled in a plan that covered MOUD, 53.2% of all MCO- and FFS-enrolled beneficiaries were subject to PA. Results also showed wide state variation in MCO plan coverage and PA policies for MOUD and the percentage of Medicaid beneficiaries subject to PA. Conclusions and Relevance This cross-sectional study found variation in MOUD coverage and PA policies across Medicaid MCO plans and FFS programs and across states. Thus, Medicaid beneficiaries' access to MOUD may be heavily influenced by their state of residency and the Medicaid plan in which they are enrolled. Left unaddressed, PA policies are likely to remain a barrier to MOUD access in the nation's Medicaid programs.
Collapse
Affiliation(s)
- Amanda J Abraham
- Department of Public Administration and Policy, University of Georgia School of Public and International Affairs, Athens
| | - Christina M Andrews
- Arnold School of Public Health, Health Services Policy and Management Department, University of South Carolina, Columbia
| | - Samantha J Harris
- Department of Health Policy and Management, Johns Hopkins University Bloomberg School of Public Health, Baltimore, Maryland
| | - Melissa M Westlake
- Arnold School of Public Health, Health Services Policy and Management Department, University of South Carolina, Columbia
| | - Colleen M Grogan
- Crown Family School of Social Work, Policy, and Practice, The University of Chicago, Illinois
| |
Collapse
|
12
|
Humphreys K, Shover CL, Andrews CM, Bohnert ASB, Brandeau ML, Caulkins JP, Chen JH, Cuéllar MF, Hurd YL, Juurlink DN, Koh HK, Krebs EE, Lembke A, Mackey SC, Larrimore Ouellette L, Suffoletto B, Timko C. Responding to the opioid crisis in North America and beyond: recommendations of the Stanford-Lancet Commission. Lancet 2022; 399:555-604. [PMID: 35122753 PMCID: PMC9261968 DOI: 10.1016/s0140-6736(21)02252-2] [Citation(s) in RCA: 184] [Impact Index Per Article: 92.0] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/22/2020] [Revised: 08/01/2021] [Accepted: 10/06/2021] [Indexed: 02/07/2023]
Affiliation(s)
- Keith Humphreys
- Department of Psychiatry and Behavioral Sciences, Stanford University School of Medicine, Stanford, CA, USA; Veterans Affairs Palo Alto Health Care System, Palo Alto, CA, USA.
| | - Chelsea L Shover
- Division of General Internal Medicine and Health Services Research, University of California Los Angeles David Geffen School of Medicine, Los Angeles, CA, USA
| | - Christina M Andrews
- Department of Health Services Policy and Management, Arnold School of Public Health, University of South Carolina, Columbia, SC, USA
| | - Amy S B Bohnert
- Department of Psychiatry and Department of Anesthesiology, University of Michigan Health System, Ann Arbor, MI, USA; Veterans Affairs Center for Clinical Management Research, Veterans Affairs Ann Arbor Healthcare System, Ann Arbor, MI, USA
| | - Margaret L Brandeau
- Department of Management Science and Engineering, Huang Engineering Center, Stanford University, Stanford, CA USA
| | | | - Jonathan H Chen
- Stanford Center for Biomedical Informatics Research, Stanford University School of Medicine, Stanford, CA, USA; Division of Hospital Medicine, Stanford University School of Medicine, Stanford, CA, USA
| | | | - Yasmin L Hurd
- Addiction Institute, Icahn School of Medicine, New York, NY, USA
| | - David N Juurlink
- Sunnybrook Health Sciences Centre, Toronto, ON, Canada; Department of Medicine, University of Toronto, Toronto, ON, Canada
| | - Howard K Koh
- Department of Health Policy and Management, Harvard T H Chan School of Public Health, Boston, MA, USA
| | - Erin E Krebs
- Department of Medicine, University of Minnesota, Minneapolis, MN, USA; Center for Care Delivery and Outcomes Research, Veterans Affairs Minneapolis Health Care System, Minneapolis, MN, USA
| | - Anna Lembke
- Department of Psychiatry and Behavioral Sciences, Stanford University School of Medicine, Stanford, CA, USA
| | - Sean C Mackey
- Department of Anesthesiology, Perioperative and Pain Medicine, Stanford University School of Medicine, Palo Alto, CA, USA
| | | | - Brian Suffoletto
- Department of Emergency Medicine, Stanford University School of Medicine, Stanford, CA, USA
| | - Christine Timko
- Department of Psychiatry and Behavioral Sciences, Stanford University School of Medicine, Stanford, CA, USA; Veterans Affairs Palo Alto Health Care System, Palo Alto, CA, USA
| |
Collapse
|
13
|
Choi S, Stein MD, Raifman J, Rosenbloom D, Clark JA. Estimating the impact on initiating medications for opioid use disorder of state policies expanding Medicaid and prohibiting substance use during pregnancy. Drug Alcohol Depend 2021; 229:109162. [PMID: 34768053 PMCID: PMC8671210 DOI: 10.1016/j.drugalcdep.2021.109162] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/12/2021] [Revised: 09/15/2021] [Accepted: 10/06/2021] [Indexed: 10/20/2022]
Abstract
BACKGROUND Medicaid expansion increased access to addiction treatment services for pregnant women. However, states' imposition of civil or criminal child abuse sanctions for drug use during pregnancy could inhibit access to treatment. We estimated the effects of Medicaid expansion on pregnant women's medications for opioid use disorder (MOUD) use, and its interaction with statutes that prohibit substance use during pregnancy. METHODS Using the Treatment Episode Dataset for Discharge (2010-2018), we identified the initial treatment episode of pregnant women with opioid use disorder (OUD). We described changes in MOUD use and estimated adjusted difference-in-differences and event study models to evaluate differences in changes in MOUD between states that prohibit substance use during pregnancy and states that do not. FINDINGS Among a total of 16,070 treatment episodes for pregnant women with OUD from 2010 to 2018, most (74%) were in states that expanded Medicaid. By one year post-expansion, the proportion of episodes receiving MOUD in states not prohibit substance use during pregnancy increased by 8.7% points (95% CI: 2.7, 14.7) from the pre-expansion period compared to a 5.6% point increase in states prohibiting substance use during pregnancy (95% CI: -3.3, 14.8). In adjusted event study analysis, the expansion was associated with an increase in MOUD use by 15.3% by year 2 in states not prohibiting versus 1.5% percentage points in states prohibiting substance use during pregnancy, respectively. CONCLUSIONS State policies prohibiting substance use during pregnancy may limit the salutary effects of Medicaid expansion for pregnant women who could benefit from MOUD treatment.
Collapse
Affiliation(s)
- Sugy Choi
- Department of Health Law, Policy & Management, Boston University School of Public Health, Boston, MA 02118, USA; Department of Population Health, New York University Grossman School of Medicine, New York, NY 10016, USA.
| | - Michael D. Stein
- Department of Health Law, Policy & Management, Boston University School of Public Health, Boston, Massachusetts 02118, USA
| | - Julia Raifman
- Department of Health Law, Policy & Management, Boston University School of Public Health, Boston, Massachusetts 02118, USA
| | - David Rosenbloom
- Department of Health Law, Policy & Management, Boston University School of Public Health, Boston, Massachusetts 02118, USA
| | - Jack A Clark
- Department of Health Law, Policy & Management, Boston University School of Public Health, Boston, Massachusetts 02118, USA
| |
Collapse
|
14
|
Stancil SL, Abdel-Rahman S, Wagner J. Developmental Considerations for the Use of Naltrexone in Children and Adolescents. J Pediatr Pharmacol Ther 2021; 26:675-695. [PMID: 34588931 DOI: 10.5863/1551-6776-26.7.675] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2020] [Accepted: 01/27/2021] [Indexed: 11/11/2022]
Abstract
Naltrexone (NTX) is a well-tolerated drug with a wide safety margin and mechanism of action that affords use across a wide variety of indications in adults and children. By antagonizing the opioid reward system, NTX can modulate behaviors that involve compulsivity or impulsivity, such as substance use, obesity, and eating disorders. Evidence regarding the disposition and efficacy of NTX is mainly derived from adult studies of substance use disorders and considerable variability exists. Developmental changes, plausible disease-specific alterations and genetic polymorphisms in NTX disposition, and pharmacodynamic pathways should be taken into consideration when optimizing the use of NTX in the pediatric population. This review highlights the current state of the evidence and gaps in knowledge regarding NTX to facilitate evidence-based pharmacotherapy of mental health conditions, for which few pharmacologic options exist.
Collapse
|
15
|
Neighbors CJ, Hussain S, O'Grady M, Manseau M, Choi S, Hu X, Burke C, Lincourt P. Predictive validity of the New York State Level of Care for Alcohol and Drug Treatment Referral (LOCADTR) for continuous engagement in treatment among individuals recommended for outpatient care. J Subst Abuse Treat 2021; 131:108559. [PMID: 34272131 DOI: 10.1016/j.jsat.2021.108559] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2021] [Revised: 05/26/2021] [Accepted: 07/04/2021] [Indexed: 11/25/2022]
Abstract
BACKGROUND The New York State (NYS) Level of Care for Alcohol and Drug Treatment Referral (LOCADTR) was launched in 2015 to determine the most appropriate level of care for individuals seeking addiction treatment. However, research has not studied its predictive validity. We examined the predictive validity of the LOCADTR recommendation for outpatient treatment by determining whether those who entered a level of care (LOC) concordant with the LOCADTR recommendation differed in continuous engagement in treatment compared to those who entered a discordant LOC. METHODS The study combined data from two NYS administrative sources, the LOCADTR database and a treatment registry. The study examined characteristics of the clients who entered concordant and discordant LOCs as well as tested for differences in continuous engagement of clients who entered discordant care compared to a propensity score-matched comparison group of clients who entered the concordant LOC. RESULTS Among clients for whom the LOCADTR recommended the outpatient LOC, concordant clients who entered the outpatient LOC were more likely to be retained in care than discordant clients who entered the inpatient LOC (aOR = 0.53; 95% CI = 0.36, 0.77). We did not observe statistical differences in continuous engagement among clients who were recommended for outpatient and entered that LOC versus those who entered the outpatient rehabilitation LOC instead (aOR = 1.08; 95% CI = 0.90, 1.30). CONCLUSION This study provides support for predictive validity of recommendations stemming from the LOCADTR. Clients, treatment providers, and payers benefited from a tool that provides clear guidance and predictively valid recommendations for treatment placement. The study found that clients were more likely to be retained in treatment for 6 months or longer if admitted to outpatient care, as recommended by the LOCADTR algorithm, rather than to inpatient treatment. One factor accounting for the longer engagement in outpatient care is the low level of continuity of care among patients being discharged from inpatient treatment.
Collapse
Affiliation(s)
- Charles J Neighbors
- Department of Population Health, New York University Grossman School of Medicine, New York, NY, USA.
| | - Shazia Hussain
- New York State Office of Addiction Services and Supports, Albany, NY, USA
| | - Megan O'Grady
- Public Health Sciences, University of Connecticut School of Medicine, Farmington, CT, USA
| | - Marc Manseau
- New York State Office of Addiction Services and Supports, Albany, NY, USA; Department of Psychiatry, New York University Grossman School of Medicine, New York, NY, USA
| | - Sugy Choi
- Department of Population Health, New York University Grossman School of Medicine, New York, NY, USA; Department of Health Law, Policy & Management, Boston University School of Public Health, Boston, MA, USA
| | - Xiaojing Hu
- New York State Office of Addiction Services and Supports, Albany, NY, USA
| | - Constance Burke
- New York State Office of Addiction Services and Supports, Albany, NY, USA
| | - Pat Lincourt
- New York State Office of Addiction Services and Supports, Albany, NY, USA
| |
Collapse
|
16
|
Barnes AJ, Cunningham PJ, Saxe-Walker L, Britton E, Sheng Y, Boynton M, Harper K, Harrell A, Bachireddy C, Montz E, Neuhausen K. Hospital Use Declines After Implementation Of Virginia Medicaid's Addiction And Recovery Treatment Services. Health Aff (Millwood) 2021; 39:238-246. [PMID: 32011949 DOI: 10.1377/hlthaff.2019.00525] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Medicaid programs responded to the opioid crisis by expanding treatment coverage and reforming delivery systems. We assessed whether Virginia's Addiction and Recovery Treatment Services (ARTS) program, implemented in April 2017, influenced emergency department and inpatient use. Using claims for January 2016-June 2018 and difference-in-differences models, we compared beneficiaries with opioid use disorder before and after ARTS implementation to beneficiaries with no substance use disorder. After program implementation, the likelihood of having an emergency department visit in a quarter declined by 9.4 percentage points (a 21.1 percent relative decrease) among beneficiaries with opioid use disorder, compared to 0.9 percentage points among beneficiaries with no substance use disorder. Similarly, the likelihood of having an inpatient hospitalization declined among beneficiaries with opioid use disorder. In contrast to other states, Virginia has a new Medicaid expansion population whose beneficiaries enter a delivery system in which reforms of the addiction treatment system are well under way.
Collapse
Affiliation(s)
- Andrew J Barnes
- Andrew J. Barnes ( abarnes3@vcu. edu ) is an associate professor in the Department of Health Behavior and Policy, Virginia Commonwealth University, in Richmond
| | - Peter J Cunningham
- Peter J. Cunningham is a professor in the Department of Health Behavior and Policy, Virginia Commonwealth University
| | - Lauryn Saxe-Walker
- Lauryn Saxe-Walker is a senior adviser in the Division of Health Economics and Economic Policy, Virginia Department of Medical Assistance Services, in Richmond
| | - Erin Britton
- Erin Britton is a research analyst in the Department of Health Behavior and Policy, Virginia Commonwealth University
| | - Yaou Sheng
- Yaou Sheng is a health data analyst in the Department of Health Behavior and Policy, Virginia Commonwealth University
| | - Melanie Boynton
- Melanie Boynton is a data analyst in the Office of Data Analytics, Virginia Department of Medical Assistance Services
| | - Ke'Shawn Harper
- Ke'Shawn Harper is the ARTS senior policy specialist in the Division of Behavioral Health, Virginia Department of Medical Assistance Services
| | - Ashley Harrell
- Ashley Harrell is a senior program adviser in the Division of Behavioral Health, Virginia Department of Medical Assistance Services
| | - Chethan Bachireddy
- Chethan Bachireddy is acting chief medical officer in the Executive Office, Virginia Department of Medical Assistance Services
| | - Ellen Montz
- Ellen Montz is chief health economist in the Division of Health Economics and Economic Policy, Virginia Department of Medical Assistance Services
| | - Kate Neuhausen
- Kate Neuhausen is an affiliate faculty in the Department of Family Medicine and Population Health, Virginia Commonwealth University
| |
Collapse
|
17
|
Wen H, Druss BG, Saloner B. Self-Help Groups And Medication Use In Opioid Addiction Treatment: A National Analysis. Health Aff (Millwood) 2021; 39:740-746. [PMID: 32364856 DOI: 10.1377/hlthaff.2019.01021] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Self-help groups and medications (buprenorphine, methadone, and naltrexone) both play important roles in opioid addiction treatment. The relative use of these two treatment modalities has not been characterized in a national study. Using national treatment data, we found that self-help groups were rarely provided in conjunction with medication treatment: Among all adult discharges from opioid addiction treatment in the period 2015-17, 10.4 percent used both self-help groups and medications, 29.2 percent used only medications, 29.8 percent used only self-help groups, and 30.5 percent used neither self-help groups nor medications. Use of self-help groups without medication is most common in residential facilities, among those with criminal justice referrals, and among uninsured or privately insured patients, as well as in the South and West regions of the US. These subgroups may be important targets for future efforts to identify and overcome barriers to medication treatment and create multimodal paths to recovery.
Collapse
Affiliation(s)
- Hefei Wen
- Hefei Wen ( hefei_wen@hphci. harvard. edu ) is a faculty member in the Division of Health Policy and Insurance Research, Department of Population Medicine, Harvard Medical School and the Harvard Pilgrim Health Care Institute, in Boston, Massachusetts
| | - Benjamin G Druss
- Benjamin G. Druss is the Rosalynn Carter Chair and a professor in the Department of Health Policy and Management, Emory University Rollins School of Public Health, in Atlanta, Georgia
| | - Brendan Saloner
- Brendan Saloner is an associate professor in the Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health, in Baltimore, Maryland
| |
Collapse
|
18
|
Ferries E, Racsa P, Bizzell B, Rhodes C, Suehs B. Removal of prior authorization for medication-assisted treatment: impact on opioid use and policy implications in a Medicare Advantage population. J Manag Care Spec Pharm 2021; 27:596-606. [PMID: 33908274 PMCID: PMC10390915 DOI: 10.18553/jmcp.2021.27.5.596] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
BACKGROUND: More than 30% of Medicare beneficiaries and 40% of patients dually eligible for Medicare and Medicaid use opioids. With an estimated 8%-12% of patients developing an opioid use disorder (OUD) after initiating opioids, opioid misuse is a significant public health challenge, especially among high-risk Medicare populations. Medication-assisted treatment (MAT) is the use of medications for the treatment of OUD and to prevent relapse to opioid use. MAT is the most effective treatment for OUD. There are a variety of barriers to MAT therapy that may delay access to treatment. OBJECTIVE: To study the impact of the removal of prior authorization requirements for MAT medications on MAT utilization, opioid utilization, and clinical outcomes, including emergency department visits, inpatient admission, relapse rates, behavioral health services, and nonopioid pain medication utilization, among opioid-using individuals with Medicare Advantage Prescription Drug (MAPD) coverage. METHODS: This retrospective, cross-sectional study used administrative medical, pharmacy, and enrollment data to identify chronic opioid users and a subset cohort initiating MAT use in 2017, when prior authorization requirements were in effect, and 2018 after removal of prior authorization requirements. Opioid and MAT utilization and clinical outcomes from emergency department visits were also examined before and after prior authorization requirements. A logistic regression analysis was conducted to examine the impact of the policy change on relapse rates, comparing relapse rates in 2017 and 2018, after controlling for potentially confounding demographic and clinical factors. RESULTS: This policy change was followed by a decrease in opioid utilization, an increase in MAT initiation, and a 4% decline in relapse rates. Patients initiating MAT after removal of prior authorizations had a 19% decrease in likelihood of relapse, and those with an OUD diagnosis were 47% less likely to relapse. The majority of MAT recipients were aged younger than 65 years, had a mental or behavioral health disorder diagnosis, and initially used relatively low doses (< 90 MME) of prescription opioids. There were no statistically significant differences in the use of behavioral health services or the use of nonopioid medications from 2017 to 2018. CONCLUSIONS: Utilization management policies should ensure appropriate MAT use, while minimizing impediments to access. Providing patients with evidence-based therapy effective for the treatment of OUD is essential to patient recovery and combating the consequences of the opioid epidemic. Further strides are needed to eliminate additional obstacles to OUD care. DISCLOSURES: No outside funding supported this study. All authors are or were employees of Humana, Inc., at the time of the study and have no other potential conflicts of interest to disclose.
Collapse
|
19
|
Dennis ML, Davis JP. Screening for more with less: Validation of the Global Appraisal of Individual Needs Quick v3 (GAIN-Q3) screeners. J Subst Abuse Treat 2021; 126:108414. [PMID: 34116811 DOI: 10.1016/j.jsat.2021.108414] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2020] [Revised: 04/12/2021] [Accepted: 04/12/2021] [Indexed: 10/21/2022]
Abstract
Multi-morbidity is the norm among adolescents and adults with substance use and other mental disorders and warrants a multi-pronged screening approach. However, the time constraints on assessment inherent in clinical practice often temper the desire for a full understanding of multi-morbidity problems. The 15- to 25-minute Global Appraisal of Individual Needs Quick version 3 (GAIN-Q3) includes screeners for 9 common clinical problems that are short (4 to 10 items) and provide dimensional measures of problem severity in each area that are also categorized to guide clinical decision making. The screeners are summed into a total score that represents a 10th screener for multi-morbidity. This paper provides background on the development of the GAIN-Q3 screeners, their psychometric behaviors, efficiency, and predictive power relative to the 1-2 h full GAIN-I. Based on literature showing differential item and scale functioning by age, analyses were conducted separately using data from 10,625 adolescent and 10,167 adult treatment clients. Despite the condensed lengths of the screening measures compared with their longer versions, the reliability estimates are within the good to excellent range (0.7 to 0.9) in terms of internal consistency for 6 of the 10 screeners for adolescents and 7 of the 10 screeners for adults. In addition, the part to whole correlation for all 10 comparisons for both adolescents and adults are excellent (0.82 to 0.96). Moreover, there is strong evidence for the measures' convergent and discriminant validity and efficiency (i.e., maximum information gathered in as few items possible) relative to the full-length scales as well as relative to other scales in the full GAIN-I. Analyses of the interpretive cut-scores provide accurate identification of cases with high sensitivity and specificity, thus supporting the screeners' capacity to triage. PUBLIC SIGNIFICANCE STATEMENT: This study reports on the ability (GAIN-Q3) to efficiently screen for multiple co-occurring substance use, mental health, and associated problems. Multi-problem presentation in the social service sector is the normal expectation, yet time constraints prevent broad assessment of potentially many problematic areas. The GAIN-Q3 showed convergent and discriminant validity relative to the full-length scales as well as other scales assessed in the GAIN-I. The GAIN-Q3 achieves the desired balance between broad coverage and measurement efficiency to provide ample information to identify the best course of action for an individual.
Collapse
Affiliation(s)
- Michael L Dennis
- Chestnut Health Systems, GAIN Coordinating Center, Normal, IL, United States of America.
| | - Jordan P Davis
- Suzanne Dworak-Peck School of Social Work, USC Center for Artificial Intelligence in Society, USC Center for Mindfulness Science, USC Institute for Addiction Science, University of Southern California, United States of America
| |
Collapse
|
20
|
Assessing public behavioral health services data: a mixed method analysis. SUBSTANCE ABUSE TREATMENT PREVENTION AND POLICY 2020; 15:85. [PMID: 33176839 PMCID: PMC7661157 DOI: 10.1186/s13011-020-00328-9] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Accepted: 10/30/2020] [Indexed: 11/17/2022]
Abstract
Background Measuring behavioral health treatment accessibility requires timely, comprehensive and accurate data collection. Existing public sources of data have inconsistent metrics, delayed times to publication and do not measure all factors related to accessibility. This study seeks to capture this additional information and determine its importance for informing accessibility and care coordination. Methods The 2018 National Survey for Substance Abuse and Treatment Services (N-SSATS) data were used to identify behavioral health facilities in Indiana and gather baseline information. A telephone survey was administered to facilities with questions parallel to the N-SSATS and additional questions regarding capacity and patient intake. Quantitative analysis includes chi-square tests. A standard qualitative analysis was used for theming answers to open-ended questions. Results About 20% of behavioral health facilities responded to the study survey, and non-response bias was identified by geographic region. Among respondents, statistically significant differences were found in several questions asked in both the study survey and N-SSATS. Data gathered from the additional questions revealed many facilities to have wait times to intake longer than 2 weeks, inconsistency in intake assessment tools used, limited capacity for walk-ins and numerous requirements for engaging in treatment. Conclusion Despite the low response rate to this study survey, results demonstrate that multiple factors not currently captured in public data sources can influence coordination of care. The questions included in this study survey could serve as a framework for routinely gathering these data and can facilitate efforts for successful coordination of care and clinical decision-making.
Collapse
|
21
|
Lewis R, Baugher AR, Finlayson T, Wejnert C, Sionean C. Healthcare Access and Utilization Among Persons Who Inject Drugs in Medicaid Expansion and Nonexpansion States: 22 United States Cities, 2018. J Infect Dis 2020; 222:S420-S428. [PMID: 32877551 PMCID: PMC11290347 DOI: 10.1093/infdis/jiaa337] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022] Open
Abstract
BACKGROUND Medicaid expansion under the Affordable Care Act increased insurance coverage, access to healthcare, and substance use disorder treatment, for many Americans. We assessed differences in healthcare access and utilization among persons who inject drugs (PWID) by state Medicaid expansion status. METHODS In 2018, PWID were interviewed in 22 US cities for National HIV Behavioral Surveillance. We analyzed data from PWID aged 18-64 years who reported illicit use of opioids (n = 9957) in the past 12 months. Poisson regression models with robust standard errors were used to estimate adjusted prevalence ratios (aPRs) and 95% confidence intervals (CIs) were used to examine differences by Medicaid expansion status in indicators of healthcare access and utilization. RESULTS Persons who inject drugs in Medicaid expansion states were more likely to have insurance (87% vs 36%; aPR, 2.3; 95% CI, 2.0-2.6), a usual source of healthcare (53% vs 34%; aPR, 1.5; 95% CI, 1.3-1.9), and have used medication-assisted treatment (61% vs 36%; aPR, 1.4; 95% CI, 1.1-1.7), and they were less likely to have an unmet need for care (21% vs 39%; aPR, 0.6; 95% CI, 0.4-0.7) than those in nonexpansion states. CONCLUSIONS Low insurance coverage, healthcare access, and medication-assisted treatment utilization among PWID in some areas could hinder efforts to end the intertwined human immunodeficiency virus and opioid overdose epidemics.
Collapse
Affiliation(s)
- Rashunda Lewis
- Division of HIV/AIDS Prevention, National Center for HIV, Viral Hepatitis, STD, and TB Prevention, Centers for Disease Control and Prevention, Atlanta, Georgia, USA
| | - Amy R Baugher
- Division of HIV/AIDS Prevention, National Center for HIV, Viral Hepatitis, STD, and TB Prevention, Centers for Disease Control and Prevention, Atlanta, Georgia, USA
| | - Teresa Finlayson
- Division of HIV/AIDS Prevention, National Center for HIV, Viral Hepatitis, STD, and TB Prevention, Centers for Disease Control and Prevention, Atlanta, Georgia, USA
| | - Cyprian Wejnert
- Division of HIV/AIDS Prevention, National Center for HIV, Viral Hepatitis, STD, and TB Prevention, Centers for Disease Control and Prevention, Atlanta, Georgia, USA
| | - Catlainn Sionean
- Division of HIV/AIDS Prevention, National Center for HIV, Viral Hepatitis, STD, and TB Prevention, Centers for Disease Control and Prevention, Atlanta, Georgia, USA
| |
Collapse
|
22
|
Satre DD, Palzes VA, Young-Wolff KC, Parthasarathy S, Weisner C, Guydish J, Campbell CI. Healthcare utilization of individuals with substance use disorders following Affordable Care Act implementation in a California healthcare system. J Subst Abuse Treat 2020; 118:108097. [PMID: 32972648 DOI: 10.1016/j.jsat.2020.108097] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2020] [Revised: 06/24/2020] [Accepted: 07/25/2020] [Indexed: 01/08/2023]
Abstract
BACKGROUND Practitioners expected the Affordable Care Act (ACA) to increase availability of health services and access to treatment for Americans with substance use disorders (SUDs). Yet research has not examined the associations among ACA enrollment mechanisms, deductibles, and the use of SUD treatment and other healthcare services. Understanding these relationships can inform future healthcare policy. METHODS We conducted a longitudinal analysis of patients with SUDs newly enrolled in the Kaiser Permanente Northern California health system in 2014 (N = 6957). Analyses examined the likelihood of service utilization (primary care, specialty SUD treatment, psychiatry, inpatient, and emergency department [ED]) over three years after SUD diagnosis, and associations with enrollment mechanisms (ACA Exchange vs. other), deductibles (none, $1-$999 [low] and ≥$1000 [high]), membership duration, psychiatric comorbidity, and demographic characteristics. We also evaluated whether the enrollment mechanism moderated the associations between deductible limits and utilization likelihood. RESULTS Service utilization was highest in the 6 months after SUD diagnosis, decreased in the following 6 months, and remained stable in years 2-3. Relative to patients with no deductible, those with a high deductible had lower odds of using all health services except SUD treatment; associations with primary care and psychiatry were strongly negative among Exchange enrollees. Among non-Exchange enrollees, patients with deductibles were more likely than those without deductibles to receive SUD treatment. Exchange enrollment compared to other mechanisms was associated with less ED use. Psychiatric comorbidity was associated with greater use of all services. Nonwhite patients were less likely to initiate SUD and psychiatry treatment. CONCLUSIONS Higher deductibles generally were associated with use of fewer health services, especially in combination with enrollment through the Exchange. The role of insurance factors, psychiatric comorbidity and race/ethnicity in health services for people with SUDs are important to consider as health policy evolves.
Collapse
Affiliation(s)
- Derek D Satre
- Department of Psychiatry and Behavioral Sciences, Weill Institute for Neurosciences, University of California, San Francisco, 401 Parnassus Avenue, Box 0984, San Francisco, CA 94143, United States of America; Division of Research, Kaiser Permanente Northern California Region, 2000 Broadway, 3rd Floor, Oakland, CA 94612, United States of America.
| | - Vanessa A Palzes
- Division of Research, Kaiser Permanente Northern California Region, 2000 Broadway, 3rd Floor, Oakland, CA 94612, United States of America
| | - Kelly C Young-Wolff
- Department of Psychiatry and Behavioral Sciences, Weill Institute for Neurosciences, University of California, San Francisco, 401 Parnassus Avenue, Box 0984, San Francisco, CA 94143, United States of America; Division of Research, Kaiser Permanente Northern California Region, 2000 Broadway, 3rd Floor, Oakland, CA 94612, United States of America
| | - Sujaya Parthasarathy
- Division of Research, Kaiser Permanente Northern California Region, 2000 Broadway, 3rd Floor, Oakland, CA 94612, United States of America
| | - Constance Weisner
- Department of Psychiatry and Behavioral Sciences, Weill Institute for Neurosciences, University of California, San Francisco, 401 Parnassus Avenue, Box 0984, San Francisco, CA 94143, United States of America; Division of Research, Kaiser Permanente Northern California Region, 2000 Broadway, 3rd Floor, Oakland, CA 94612, United States of America
| | - Joseph Guydish
- Department of Psychiatry and Behavioral Sciences, Weill Institute for Neurosciences, University of California, San Francisco, 401 Parnassus Avenue, Box 0984, San Francisco, CA 94143, United States of America; Institute for Health Policy Studies, University of California, San Francisco, 3333 California Street, San Francisco, CA 94118, United States of America
| | - Cynthia I Campbell
- Department of Psychiatry and Behavioral Sciences, Weill Institute for Neurosciences, University of California, San Francisco, 401 Parnassus Avenue, Box 0984, San Francisco, CA 94143, United States of America; Division of Research, Kaiser Permanente Northern California Region, 2000 Broadway, 3rd Floor, Oakland, CA 94612, United States of America
| |
Collapse
|
23
|
Abstract
Medicaid's experience one decade after the passage of the Affordable Care Act represents extreme divergence across the American states in health care access and utilization, policy designs that either expand or restrict eligibility, and delivery model reforms. The past decade has also witnessed a growing ideological divide about the very purpose and intent of the Medicaid program and its place within the US health care system. While liberal-leaning states have actively embraced the program and used it to expand health coverage to working adults and families as an effort to improve health and prevent poverty and the insecurity and instability that comes with high medical costs (evictions, bankruptcy), conservative states have actively rejected this expanded idea of Medicaid and argued instead that the program should revert back to its "original" purpose and be used only for the "truly" needy. This article highlights several paradoxes within Medicaid that have led to this growing bifurcation, and it concludes by shedding light on important targets for future reform.
Collapse
|
24
|
Burns ME, Dague L, Saloner B, Voskuil K, Kim NH, Serna Borrero N, Look K. Implementing parity for mental health and substance use treatment in Medicaid. Health Serv Res 2020; 55:604-614. [PMID: 32578233 DOI: 10.1111/1475-6773.13309] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
OBJECTIVE To estimate the association between the implementation of parity in coverage for mental health and substance use disorder (MHSUD) services within the Medicaid program and MHSUD service use. DATA SOURCES/STUDY SETTING Wisconsin Medicaid enrollment and claims data from 2013 to 2015. In April 2014, Wisconsin Medicaid transitioned childless adult beneficiaries from coverage with limited MHSUD services to parity-consistent coverage. Preparity, they only had Medicaid coverage for MHSUD visits to psychiatrists and the emergency department, while parent beneficiaries had parity-consistent coverage. STUDY DESIGN The study uses a difference-in-differences design to compare outcome changes for childless adult and parent beneficiaries. DATA COLLECTION/EXTRACTION METHODS We identified 76, 569 childless adult and parent beneficiaries aged 18-64 who were continuously enrolled for the 2-year study period. PRINCIPAL FINDINGS Introducing parity-consistent coverage within Medicaid was associated with increased utilization of Medicaid-reimbursed MHSUD services: outpatient, prescription medication, ED, and inpatient. Increased MHSUD outpatient visits were driven by increased visits to nonpsychiatrists. CONCLUSIONS Parity's effects on MHSUD service use have been studied in the context of private insurance, but its impact among Medicaid beneficiaries has not. Our findings suggest that parity implementation in Medicaid could increase access to effective MHSUD services in a high-need population.
Collapse
Affiliation(s)
- Marguerite E Burns
- School of Medicine and Public Health, University of Wisconsin-Madison, Madison, Wisconsin
| | - Laura Dague
- Texas A&M University, College Station, Texas
| | - Brendan Saloner
- Health Policy and Management, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland
| | - Kristen Voskuil
- Institute for Research on Poverty, University of Wisconsin-Madison, Madison, Wisconsin
| | - Nam Hyo Kim
- School of Pharmacy, University of Wisconsin-Madison, Madison, Wisconsin
| | | | - Kevin Look
- Social & Administrative Sciences, School of Pharmacy, University of Wisconsin-Madison, Madison, Wisconsin
| |
Collapse
|
25
|
Coupet E, Werner RM, Polsky D, Karp D, Delgado MK. Impact of the Young Adult Dependent Coverage Expansion on Opioid Overdoses and Deaths: a Quasi-Experimental Study. J Gen Intern Med 2020; 35:1783-1788. [PMID: 31898130 PMCID: PMC7280374 DOI: 10.1007/s11606-019-05605-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/21/2019] [Revised: 09/27/2019] [Accepted: 12/05/2019] [Indexed: 12/31/2022]
Abstract
BACKGROUND Several policymakers have suggested that the Affordable Care Act (ACA) has fueled the opioid epidemic by subsidizing opioid pain medications. These claims have supported numerous efforts to repeal the ACA. OBJECTIVE To determine the effect of the ACA's young adult dependent coverage insurance expansion on emergency department (ED) encounters and out-of-hospital deaths from opioid overdose. DESIGN Difference-in-differences analyses comparing ED encounters and out-of-hospital deaths before (2009) and after (2011-2013) the ACA young adult dependent coverage expansion. We further stratified by prescription opioid, non-prescription opioid, and methadone overdoses. PARTICIPANTS Adults aged 23-25 years old and 27-29 years old who presented to the ED or died prior to reaching the hospital from opioid overdose. MAIN MEASURES Rate of ED encounters and deaths for opioid overdose per 100,000 U.S. adults. KEY RESULTS There were 108,253 ED encounters from opioid overdose in total. The expansion was not associated with a significant change in the ED encounter rates for opioid overdoses of all types (2.04 per 100,000 adults [95% CI - 0.75 to 4.82]), prescription opioids (0.60 per 100,000 adults [95% CI - 1.98 to 0.77]), or methadone (0.29 per 100,000 adults [95% CI - 0.78 to 0.21]). There was a slight increase in the rate of non-prescription opioid overdoses (1.91 per 100,000 adults [95% CI 0.13-3.71]). The expansion was not associated with a significant change in the out-of-hospital mortality rates for opioid overdoses of all types (0.49 per 100,000 adults [95% CI - 0.80 to 1.78]). CONCLUSIONS Our findings do not support claims that the ACA has fueled the prescription opioid epidemic. However, the expansion was associated with an increase in the rate of ED encounters for non-prescription opioid overdoses such as heroin, although almost all were non-fatal. Future research is warranted to understand the role of private insurance in providing access to treatment in this population.
Collapse
Affiliation(s)
- Edouard Coupet
- Department of Emergency Medicine, Yale School of Medicine, Yale University, 464 Congress Avenue, Suite 260, New Haven, CT, 06519, USA.
- Yale Drug Use, Addiction, and HIV Research Scholars (DAHRS) Program, New Haven, USA.
- Center for Health Incentives and Behavioral Economics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, USA.
| | - Rachel M Werner
- Center for Health Incentives and Behavioral Economics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, USA
- Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, USA
- Department of Health Care Management, The Wharton School, University of Pennsylvania, Philadelphia, USA
| | - Daniel Polsky
- Center for Health Incentives and Behavioral Economics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, USA
- Department of Health Care Management, The Wharton School, University of Pennsylvania, Philadelphia, USA
- Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, USA
- Department of Health Economics, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, USA
| | - David Karp
- Center for Health Incentives and Behavioral Economics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, USA
- Center for Emergency Care Policy and Research, Department of Emergency Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, USA
| | - M Kit Delgado
- Center for Health Incentives and Behavioral Economics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, USA
- Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, USA
- Center for Emergency Care Policy and Research, Department of Emergency Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, USA
- Department of Biostatistics, Epidemiology, and Informatics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, USA
- Penn Injury Science Center, University of Pennsylvania, Philadelphia, USA
| |
Collapse
|
26
|
Changes in Medicaid Acceptance by Substance Abuse Treatment Facilities After Implementation of Federal Parity. Med Care 2020; 58:101-107. [PMID: 31688556 DOI: 10.1097/mlr.0000000000001242] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Adequate access for mental illness and substance use disorder (SUD) treatment, particularly for Medicaid enrollees, is challenging. Policy efforts, including the Mental Health Parity and Addiction Equity Act (MHPAEA), have targeted expanded access to care. With MHPAEA, more Medicaid plans were required to increase their coverage of SUD treatment, which may impact provider acceptance of Medicaid. OBJECTIVES To identify changes in Medicaid acceptance by SUD treatment facilities after the implementation of MHPAEA (parity). RESEARCH DESIGN Observational study using an interrupted time series design. SUBJECTS 2002-2013 data from the National Survey of Substance Abuse Treatment Services (N-SSATS) for all SUD treatment facilities was combined with state-level characteristics. MEASURES Primary outcome is whether a SUD treatment facility reported accepting Medicaid insurance. RESULTS Implementation of MHPAEA was associated with a 4.6 percentage point increase in the probability of an SUD treatment facility accepting Medicaid (P<0.001), independent of facility and state characteristics, time trends, and key characteristics of state Medicaid programs. CONCLUSIONS After parity, more SUD treatment facilities accepted Medicaid payments, which may ultimately increase access to care for individuals with SUD. The findings underscore how parity laws are critical policy tools for creating contexts that enable historically vulnerable and underserved populations with SUD to access needed health care.
Collapse
|
27
|
Wen H, Soni A, Hollingsworth A, Freedman S, Benitez J, Simon K, Saloner B. Association Between Medicaid Expansion and Rates of Opioid-Related Hospital Use. JAMA Intern Med 2020; 180:753-759. [PMID: 32202609 PMCID: PMC7091455 DOI: 10.1001/jamainternmed.2020.0473] [Citation(s) in RCA: 21] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
IMPORTANCE The rate of opioid-related emergency department (ED) visits and inpatient hospitalizations has increased rapidly in recent years. Medicaid expansions have the potential to reduce overall opioid-related hospital events by improving access to outpatient treatment for opioid use disorder. OBJECTIVE To examine the association between Medicaid expansions and rates of opioid-related ED visits and inpatient hospitalizations. DESIGN, SETTING, AND PARTICIPANTS A difference-in-differences observational design was used to compare changes in opioid-related hospital events in US nonfederal, nonrehabilitation hospitals in states that implemented Medicaid expansions between the first quarter of 2005 and the last quarter of 2017 with changes in nonexpansion states. All-payer ED and hospital discharges from 45 states in the Healthcare Cost and Utilization Project FastStats were included. EXPOSURES State implementation of Medicaid expansions between 2005 and 2017. MAIN OUTCOMES AND MEASURES Rates of all opioid-related ED visits and inpatient hospitalizations, measured as the quarterly numbers of treat-and-release ED discharges and hospital discharges related to opioid abuse, dependence, and overdose, per 100 000 state population. RESULTS In the 46 states and District of Columbia included in the study, 1524 observations of emergency department data and 2219 observations of opioid-related inpatient hospitalizations were analyzed. The post-2014 Medicaid expansions were associated with a 9.74% (95% CI, -18.83% to -0.65%) reduction in the rate of opioid-related inpatient hospitalizations. There appeared to be no association between the pre-2014 or post-2014 Medicaid expansions and the rate of opioid-related ED visits (post-2014 Medicaid expansions, -3.98%; 95% CI, -14.69% to 6.72%; and pre-2014 Medicaid expansions, 1.02%; 95% CI, -5.25% to 7.28%). CONCLUSIONS AND RELEVANCE Medicaid expansion appears to be associated with meaningful reductions in opioid-related hospital use, possibly attributable to improved care for opioid use disorder in other settings.
Collapse
Affiliation(s)
- Hefei Wen
- Harvard Pilgrim Health Care Institute, Division of Health Policy and Insurance Research, Department of Population Medicine, Harvard Medical School, Boston, Massachusetts
| | - Aparna Soni
- School of Public Affairs, Department of Public Administration and Policy, American University, Washington, DC
| | - Alex Hollingsworth
- O'Neill School of Public and Environmental Affairs, Indiana University, Bloomington, Indiana
| | - Seth Freedman
- O'Neill School of Public and Environmental Affairs, Indiana University, Bloomington, Indiana
| | - Joseph Benitez
- College of Public Health, Department of Health Management & Policy, University of Kentucky, Lexington, Kentucky
| | - Kosali Simon
- O'Neill School of Public and Environmental Affairs, Indiana University, Bloomington, Indiana.,National Bureau of Economic Research, Cambridge, Massachusetts
| | - Brendan Saloner
- Department of Health Policy and Management, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, Maryland
| |
Collapse
|
28
|
Madras BK, Ahmad NJ, Wen J, Sharfstein JS. Improving Access to Evidence-Based Medical Treatment for Opioid Use Disorder: Strategies to Address Key Barriers within the Treatment System. NAM Perspect 2020; 2020:202004b. [PMID: 35291732 PMCID: PMC8916813 DOI: 10.31478/202004b] [Citation(s) in RCA: 96] [Impact Index Per Article: 24.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/20/2023]
Abstract
Even though evidence-based treatment for opioid use disorders (OUD) is effective, almost four in five Americans with OUD do not receive any form of treatment. The gap in access to evidence-based care, including treatment with medications for OUD, stems in part from barriers to change within the health care system. This paper includes nine key barriers that prevent access to evidence-based care, including stigma; inadequate clinical training; a dearth of addiction specialists; lack of integration of MOUD provision in practice; regulatory, statutory, and data sharing restrictions; and financial barriers. Action from a number of actors is urgently needed to address this crisis.
Collapse
Affiliation(s)
| | - N Jia Ahmad
- Johns Hopkins Bloomberg School of Public Health
| | - Jenny Wen
- Johns Hopkins University School of Medicine
| | - Joshua Sharfstein Sharfstein
- Johns Hopkins Bloomberg School of Public Health; and the Prevention, Treatment, and Recovery Working Group of the Action Collaborative on Countering the U.S. Opioid Epidemic
| |
Collapse
|
29
|
Mark TL, Parish WJ, Zarkin GA. Association of Formulary Prior Authorization Policies With Buprenorphine-Naloxone Prescriptions and Hospital and Emergency Department Use Among Medicare Beneficiaries. JAMA Netw Open 2020; 3:e203132. [PMID: 32310285 PMCID: PMC7171554 DOI: 10.1001/jamanetworkopen.2020.3132] [Citation(s) in RCA: 29] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/01/2023] Open
Abstract
IMPORTANCE Prior authorization requirements may be a barrier to accessing medications for opioid use disorder treatment and may, therefore, be associated with poor health care outcomes. OBJECTIVE To determine the association of prior authorization with use of buprenorphine-naloxone and health care outcomes. DESIGN, SETTING, AND PARTICIPANTS This comparative interrupted time series analysis examined enrollment and insurance claims data from Medicare beneficiaries with an opioid use disorder diagnosis or who filled a prescription for an opioid use disorder medication between 2012 and 2017. Over this period, 775 874 members were in 1479 Part D plans that always required prior authorization, 113 286 members were in 206 plans that removed prior authorization, 189 461 members were in 489 plans that never required prior authorization, and 619 919 members were in 485 plans that added prior authorization. Data analysis was performed from April 2019 to February 2020. EXPOSURES Removal or addition of prior authorization and new prescriptions filled for buprenorphine-naloxone. MAIN OUTCOMES AND MEASURES Buprenorphine-naloxone use, inpatient admissions, emergency department visits, and prescription drug and medical expenditures. RESULTS The study population in 2012 included 949 206 Medicare beneficiaries (mean [SD] age, 57 [15] years; 550 445 women [58%]). Removal of prior authorization was associated with an increase of 17.9 prescriptions (95% CI, 1.1 to 34.7 prescriptions) filled for buprenorphine-naloxone per plan per year, which is a doubling of the number of prescriptions, on average. Each prescription filled was associated with statistically significant decreases in adverse health care outcomes: substance use disorder-related inpatient admissions decreased by 0.1 admission per plan per year (95% CI, -0.2 to -0.1 admission per plan per year), and substance use disorder-related emergency department visits decreased by 0.1 visit per plan per year (95% CI, -0.13 to -0.03 visit per plan per year) (all P < .001). Combining these results, removal of prior authorization was associated with a reduction in substance use disorder-related inpatient admissions by 2.0 admissions per plan per year (95% CI, -4.3 to -0.1 admissions per plan per year) and substance use disorder-related emergency department visits by 1.4 visits per plan per year (95% CI, -3.2 to -0.1 visits per plan per year). CONCLUSIONS AND RELEVANCE Removing prior authorization for buprenorphine-naloxone was associated with an increase in the medication use and decreases in health care utilization and expenditures.
Collapse
|
30
|
Varley AL, Lappan S, Jackson J, Goodin BR, Cherrington AL, Copes H, Hendricks PS. Understanding Barriers and Facilitators to the Uptake of Best Practices for the Treatment of Co-Occurring Chronic Pain and Opioid Use Disorder. J Dual Diagn 2020; 16:239-249. [PMID: 31769729 PMCID: PMC10763074 DOI: 10.1080/15504263.2019.1675920] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
Objective: Patients with a combination of chronic pain and opioid use disorder have unique needs and may present a challenge for clinicians and health care systems. The objective of the present study was to use qualitative methods to explore factors influencing the uptake of best practices for co-occurring chronic pain and opioid use disorder in order to inform a quantitative survey assessing primary care provider capacity to appropriately treat this dual diagnosis. Methods: Guided by the Consolidated Framework for Implementation Research (CFIR), semi-structured qualitative interviews were conducted with 11 primary care providers (PCPs) to inform the development of a questionnaire. Interviews were audio-recorded and transcribed verbatim. Fifteen comments from an open-ended question on the questionnaire were added to the analyses as they described factors that were not elucidated in the interviews. Barriers and facilitators were identified and categorized using the CFIR codebook. Results: The most frequently described barriers were cost and inadequate access to appropriate treatments, external policies, and available resources (e.g., risk assessment tools). The most frequently described facilitators were the presence of a network or team, patient-specific needs, and the learning climate. Knowledge and beliefs were frequently described as both barriers and facilitators. Conclusions: While substantial funding has been allocated to initiatives aimed at increasing PCP capacity to treat this population, numerous barriers to adopting appropriate practices still exist. Future research should focus on developing and testing implementation strategies that leverage the facilitators and overcome the barriers illustrated here to improve the uptake of evidence-based recommendations for the treatment of co-occurring chronic pain and opioid use disorder.
Collapse
Affiliation(s)
- Allyson L Varley
- Department of Health Behavior, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Sara Lappan
- Department of Health Behavior, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Juliet Jackson
- Department of Social Work, University of Alabama, Tuscaloosa, Alabama, USA
| | - Burel R Goodin
- Department of Psychology, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Andrea L Cherrington
- Division of Preventive Medicine, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Heith Copes
- Department of Criminal Justice, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Peter S Hendricks
- Department of Health Behavior, University of Alabama at Birmingham, Birmingham, Alabama, USA
| |
Collapse
|
31
|
Gertner AK, Robertson AG, Jones H, Powell BJ, Silberman P, Domino ME. The effect of Medicaid expansion on use of opioid agonist treatment and the role of provider capacity constraints. Health Serv Res 2020; 55:383-392. [PMID: 32166761 DOI: 10.1111/1475-6773.13282] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Abstract
OBJECTIVE To determine the effect of Medicaid expansion on the use of opioid agonist treatment for opioid use disorder (OUD) and to examine heterogeneous effects by provider supply and Medicaid acceptance rates. DATA SOURCES Yearly state-level data on methadone dispensed from opioid treatment programs (OTPs), buprenorphine dispensed from OTPs and pharmacies, number of OTPs and buprenorphine-waivered providers, and percent of OTPs and physicians accepting Medicaid. STUDY DESIGN This study used difference-in-differences models to examine the effect of Medicaid expansion on the amount of methadone and buprenorphine dispensed in states between 2006 and 2017. Interaction terms were used to estimate heterogeneous effects. Sensitivity analyses included testing the association of outcomes with Medicaid enrollment and state insurance rates. PRINCIPAL FINDINGS The estimated effects of Medicaid expansion on buprenorphine and methadone dispensed were positive but imprecise, meaning we could not rule out negative or null effects of expansion. The estimated associations between state insurance rates and dispensed methadone and buprenorphine were centered near zero, suggesting that improvements in health coverage may not have increased OUD treatment use. The effect of Medicaid expansion was larger in the states with the most waivered providers compared to states with the fewest waivered providers. In the states with the most waivered providers, the average estimated effect of expansion on buprenorphine dispensed was 12 kg/y, enough to treat about 7500 individuals. We did not find evidence that the effect of expansion was consistently modified by OTP concentration, OTP Medicaid acceptance, or physician Medicaid acceptance. CONCLUSIONS Gains in health coverage may not be sufficient to increase OUD treatment, even in the context of high treatment need. Provider capacity likely limited Medicaid expansion's effect on buprenorphine dispensed. Policies to increase buprenorphine providers, such as ending the waiver requirement, may be needed to ensure coverage gains translate to treatment access.
Collapse
Affiliation(s)
- Alex K Gertner
- Department of Health Policy and Management, University of North Carolina Gillings School of Global Public Health, Chapel Hill, North Carolina
| | - Allison G Robertson
- Department of Psychiatry and Behavioral Sciences, Duke University School of Medicine, Durham, North Carolina
| | - Hendree Jones
- Department of Obstetrics and Gynecology, University of North Carolina School of Medicine, Carrboro, North Carolina
| | - Byron J Powell
- Brown School, Washington University in St. Louis, St. Louis, Missouri
| | - Pam Silberman
- Department of Health Policy and Management, University of North Carolina Gillings School of Global Public Health, Chapel Hill, North Carolina
| | - Marisa E Domino
- Department of Health Policy and Management, University of North Carolina Gillings School of Global Public Health, Chapel Hill, North Carolina
| |
Collapse
|
32
|
Andrilla CHA, Jones KC, Patterson DG. Prescribing Practices of Nurse Practitioners and Physician Assistants Waivered to Prescribe Buprenorphine and the Barriers They Experience Prescribing Buprenorphine. J Rural Health 2020; 36:187-195. [DOI: 10.1111/jrh.12404] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/20/2023]
Affiliation(s)
- C. Holly A. Andrilla
- WWAMI Rural Health Research CenterDepartment of Family MedicineUniversity of Washington School of Medicine Seattle Washington
| | - Kendall C. Jones
- WWAMI Rural Health Research CenterDepartment of Family MedicineUniversity of Washington School of Medicine Seattle Washington
| | - Davis G. Patterson
- WWAMI Rural Health Research CenterDepartment of Family MedicineUniversity of Washington School of Medicine Seattle Washington
| |
Collapse
|
33
|
Yarbrough CR, Abraham AJ, Adams GB. Relationship of County Opioid Epidemic Severity to Changes in Access to Substance Use Disorder Treatment, 2009-2017. Psychiatr Serv 2020; 71:12-20. [PMID: 31575353 PMCID: PMC11332380 DOI: 10.1176/appi.ps.201900150] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
OBJECTIVE The study measured the association between local opioid problem severity and changes in the availability of substance use disorder treatment programs, including the distance required for travel to treatment. METHODS A two-part, multivariable regression estimated the number of treatment facilities in the county (per 100,000 residents) and the number of miles to the nearest program (for all treatment programs, programs offering opioid use disorder medication, and programs accepting Medicaid) using data from the 2009-2017 National Directory of Drug and Alcohol Abuse Treatment Facilities. The unit of analysis was the county-year (N=28,270). RESULTS The probability of having at least one treatment program meeting the established criteria was greater in counties with a high-severity opioid problem than in counties with a low-severity problem, and the probability improved over time. In counties with a high-severity problem, the probability of having a treatment program offering buprenorphine, methadone, or both was 60.3% higher than in counties with low-severity problems. Between 2009 and 2017, the likelihood of having a treatment program that accepts Medicaid grew by 25.3%. For counties without treatment programs, the distance to the nearest program improved markedly over time, but there were no differences between distance to treatment in high-, moderate-, and low-severity status counties. CONCLUSIONS The treatment system has reduced structural barriers to treatment where it is most needed. However, these findings do not imply that the treatment system has sufficient capacity to address the present scope of the opioid crisis. Policy makers should leverage this responsiveness to incentivize additional improvements in access.
Collapse
Affiliation(s)
- Courtney R Yarbrough
- Department of Health Policy and Management, Rollins School of Public Health, Emory University, Atlanta (Yarbrough); Department of Public Administration and Policy, School of Public and International Affairs (Abraham), and Department of Health Policy and Management, School of Public Health (Adams), University of Georgia, Athens
| | - Amanda J Abraham
- Department of Health Policy and Management, Rollins School of Public Health, Emory University, Atlanta (Yarbrough); Department of Public Administration and Policy, School of Public and International Affairs (Abraham), and Department of Health Policy and Management, School of Public Health (Adams), University of Georgia, Athens
| | - Grace Bagwell Adams
- Department of Health Policy and Management, Rollins School of Public Health, Emory University, Atlanta (Yarbrough); Department of Public Administration and Policy, School of Public and International Affairs (Abraham), and Department of Health Policy and Management, School of Public Health (Adams), University of Georgia, Athens
| |
Collapse
|
34
|
Abraham AJ, Andrews CM, Harris SJ, Friedmann PD. Availability of Medications for the Treatment of Alcohol and Opioid Use Disorder in the USA. Neurotherapeutics 2020; 17:55-69. [PMID: 31907876 PMCID: PMC7007488 DOI: 10.1007/s13311-019-00814-4] [Citation(s) in RCA: 47] [Impact Index Per Article: 11.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2023] Open
Abstract
Despite high mortality rates due to opioid overdose and excessive alcohol consumption, medications for the treatment of alcohol and opioid use disorder have not been widely used in the USA. This paper provides an overview of the literature on the availability of alcohol and opioid used disorder medications in the specialty substance use disorder treatment system, other treatment settings and systems, and among providers with a federal waiver to prescribe buprenorphine. We also present the most current data on the availability of alcohol and opioid use disorder medications in the USA. These estimates show steady growth in availability of opioid use disorder medications over the past decade and a decline in availability of alcohol use disorder medications. However, overall use of medications in the USA remains low. In 2017, only 16.3% of specialty treatment programs offered any single medication for alcohol use disorder treatment and 35.5% offered any single medication for opioid use disorder treatment. Availability of buprenorphine-waivered providers has increased significantly since 2002. However, geographic disparities in access to buprenorphine remain. Some of the most promising strategies to increase availability of alcohol and opioid use disorder medications include the following: incorporating substance use disorder training in healthcare education programs, educating the substance use disorder workforce about the benefits of medication treatment, reducing stigma surrounding the use of medications, implementing medications in primary care settings, implementing integrated care models, revising regulations on methadone and buprenorphine, improving health insurance coverage of medications, and developing novel medications for the treatment of substance use disorder.
Collapse
Affiliation(s)
- Amanda J. Abraham
- School of Public and International Affairs, University of Georgia, 280F Baldwin Hall, 355 S. Jackson Street, Athens, GA 30602 USA
| | - Christina M. Andrews
- College of Social Work, University of South Carolina, 1512 Pendleton St., Room 309, Columbia, SC 29208 USA
| | - Samantha J. Harris
- School of Public and International Affairs, University of Georgia, 280F Baldwin Hall, 355 S. Jackson Street, Athens, GA 30602 USA
| | - Peter D. Friedmann
- University of Massachusetts Medical School Baystate, 280 Chestnut St., Springfield, MA 01199 USA
| |
Collapse
|
35
|
Hoffman KA, Ponce Terashima J, McCarty D. Opioid use disorder and treatment: challenges and opportunities. BMC Health Serv Res 2019; 19:884. [PMID: 31767011 PMCID: PMC6876068 DOI: 10.1186/s12913-019-4751-4] [Citation(s) in RCA: 36] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2019] [Accepted: 11/15/2019] [Indexed: 02/08/2023] Open
Abstract
BACKGROUND Addiction health service researchers have focused efforts on opioid use disorder (OUD) and strategies to address the emerging public health threats associated with the epidemics of opioid use and opioid overdose. The increase in OUD is associated with widespread access to prescription opioid analgesics, enhanced purity of heroin, the introduction of potent illicit fentanyl compounds, and a rising tide of opioid overdose fatalities. These deaths have become the face of the opioid epidemic. MAIN TEXT OUD is a chronic disorder that usually requires both medications for opioid use disorder (MOUD) and psychosocial treatment and support. Research has found that MOUD with an opioid receptor agonist (methadone), partial agonist (buprenorphine), or opioid antagonist (extended-release naltrexone) can support recovery. Despite compelling evidence that MOUD are effective, they remain underutilized. More research is needed on these therapies to understand the feasibility of implementation in clinic settings. CONCLUSION This special issue focuses on how health services research has emerged as an important contributor to efforts to control the opioid epidemic in North America and Europe.
Collapse
Affiliation(s)
- Kim A Hoffman
- Oregon Health and Science University-Portland State UniversitySchool of Public Health, 3181 SW Sam Jackson Park Rd., CB669, Portland, OR, 97239-3088, USA.
| | | | - Dennis McCarty
- Oregon Health and Science University-Portland State UniversitySchool of Public Health, 3181 SW Sam Jackson Park Rd., CB669, Portland, OR, 97239-3088, USA
| |
Collapse
|
36
|
Swartz JA, Beltran SJ. Prescription opioid availability and opioid overdose-related mortality rates in Medicaid expansion and non-expansion states. Addiction 2019; 114:2016-2025. [PMID: 31286610 DOI: 10.1111/add.14741] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/17/2018] [Revised: 02/26/2019] [Accepted: 07/01/2019] [Indexed: 01/12/2023]
Abstract
AIMS To determine whether, in the United States, higher opioid overdose-related mortality rates (OOMR) in Affordable Care Act (ACA) Medicaid expansion states relative to mortality rates in non-expansion states have been mediated by increased prescription opioid availability. DESIGN Separate mixed-effect regression models examined difference-in-difference effects of time and expansion status on Medicaid-reimbursed opioids measured in morphine milligram (mg) equivalents on all OOMR and on prescription OOMR. We used generalized structural equation models to test whether increases in Medicaid-reimbursed prescription opioid availability mediated OOMR post-Medicaid expansion. SETTING AND PARTICIPANTS This study used national, serial, cross-sectional data for Medicaid-reimbursed prescription opioids, Medicaid enrollment information and annual OOMR for any opioids and for prescription opioids from 49 states and the DC pre- (2008-13) and post-ACA Medicaid expansion (2014-16). MEASUREMENTS The outcome measures were OOOMR and Medicaid-reimbursed prescription opioid availability. The main input variables were time and ACA Medicaid expansion status. FINDINGS Medicaid expansion states had larger increases in prescription opioid availability (b = 480, 357.8, P = 0.001) compared with non-expansion states. However, the largest increases in prescription opioid availability in expansion states were between 2009 and 2011, well before the ACA Medicaid expansion. Whereas expansion states also had higher any OOMR compared with non-expansion states (b = 3.6, P = 0.011), significant differences in prescription OOMR between expansion and non-expansion states did not emerge until 2015 (b = 1.4, P = 0.014) and 2016 (b = 4.0, P = 0.004), and Medicaid-reimbursed prescription opioid availability was not a significant mediator. CONCLUSIONS Increases in Medicaid-reimbursed prescription opioid availability in Affordable Care Act Medicaid expansion states in the United States do not appear to have mediated post-Affordable Care Act Medicaid expansion mortality rate differences, but there is still a possibility of lagged effects.
Collapse
Affiliation(s)
- James A Swartz
- Jane Addams College of Social Work, University of Illinois at Chicago, Chicago, IL, USA
| | - Susanny J Beltran
- School of Social Work, University of Central Florida, Orlando, FL, USA
| |
Collapse
|
37
|
Lagisetty PA, Ross R, Bohnert A, Clay M, Maust DT. Buprenorphine Treatment Divide by Race/Ethnicity and Payment. JAMA Psychiatry 2019; 76:979-981. [PMID: 31066881 PMCID: PMC6506898 DOI: 10.1001/jamapsychiatry.2019.0876] [Citation(s) in RCA: 307] [Impact Index Per Article: 61.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
This study reports the seeming disparity in access to buprenorphine prescriptions among racial/ethnic minorities and individuals with lower income.
Collapse
Affiliation(s)
- Pooja A. Lagisetty
- Department of Medicine, University of Michigan, School of Medicine, Ann Arbor,Center for Clinical Management Research, VA Ann Arbor Healthcare System, Ann Arbor, Michigan,Institute for Health Policy and Innovation, Ann Arbor, Michigan
| | - Ryan Ross
- Department of Biostatistics, University of Michigan, School of Public Health, Ann Arbor
| | - Amy Bohnert
- Center for Clinical Management Research, VA Ann Arbor Healthcare System, Ann Arbor, Michigan,Institute for Health Policy and Innovation, Ann Arbor, Michigan,Department of Psychiatry, University of Michigan, School of Medicine, Ann Arbor
| | - Michael Clay
- Department of Medicine, University of Michigan, School of Medicine, Ann Arbor,VA Ann Arbor Healthcare System, Ann Arbor, Michigan
| | - Donovan T. Maust
- Center for Clinical Management Research, VA Ann Arbor Healthcare System, Ann Arbor, Michigan,Institute for Health Policy and Innovation, Ann Arbor, Michigan,Department of Psychiatry, University of Michigan, School of Medicine, Ann Arbor
| |
Collapse
|
38
|
Shover CL, Abraham A, D'Aunno T, Friedmann PD, Humphreys K. The relationship of Medicaid expansion to psychiatric comorbidity care within substance use disorder treatment programs. J Subst Abuse Treat 2019; 105:44-50. [PMID: 31443890 DOI: 10.1016/j.jsat.2019.07.012] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/01/2019] [Revised: 05/31/2019] [Accepted: 07/22/2019] [Indexed: 10/26/2022]
Abstract
BACKGROUND Co-occurring mental health disorders are common among substance use disorder (SUD) patients. Medicaid expansion aimed to reduce barriers to SUD and mental health care and thereby improve treatment outcomes. METHODS We estimated change in the proportion of United States SUD treatment sites offering treatment for psychiatric comorbidities following Medicaid expansion as part of implementation of the Affordable Care Act (ACA) in 2014. Using panel data from the 2013-2014, n = 660, and 2016-2017, n = 638, waves of the National Drug Abuse Treatment System Survey (NDATSS), we estimated change in the proportion of sites offering antidepressant medication, other psychiatric medication, behavioral treatment, or any combination thereof for treatment of mental health comorbidities (i.e., beyond services focused on SUD). We modeled the impact of Medicaid expansion as an interaction between year and date of Medicaid expansion. We constructed a mixed-effects linear regression model for each outcome, with the interaction variable as the main exposure, site as a random effect, and site's average duration of treatment, proportion of clients with psychiatric comorbidities, average caseload per treatment prescribing-clinician on staff, type of facility and geographic region as covariates, to estimate a difference-in-differences (D-I-D) equation. RESULTS The adjusted D-I-D analysis indicated that the proportion of SUD treatment sites offering antidepressants for psychiatric treatment increased 10% (95% CI 1%, 18%) in the Medicaid expansion sites compared to non-expansion sites. The D-I-D for other psychiatric medications was also 10% (95% 1%, 19%). No significant changes were observed in behavioral treatment or the combination measure. The strongest association between Medicaid expansion and offering medication for mental health comorbidities was the 34% increase observed for residential treatment settings (95% CI 10%, 59%). CONCLUSION Availability of psychiatric medication treatment in SUD treatment settings increased following Medicaid expansion, particularly in residential SUD facilities. This policy change has facilitated integrated treatment for the substantial share of SUD treatment patients with mental health comorbidities, with the greatest benefit for patients receiving SUD treatment in residential programs.
Collapse
Affiliation(s)
- Chelsea L Shover
- Stanford University, Department of Psychiatry, 401 N. Quarry Rd., Stanford, CA 94305, United States of America.
| | - Amanda Abraham
- University of Georgia, School of Public and International Affairs, 280F Baldwin Hall, Athens, GA 30602, United States of America.
| | - Thomas D'Aunno
- New York University, Wagner Graduate School of Public Service, 295 Lafayette St., New York, NY 10012, United States of America.
| | - Peter D Friedmann
- University of Massachusetts Medical School - Baystate, Office of Research, 3601 Main St., Springfield, MA 01107, United States of America.
| | - Keith Humphreys
- Stanford University, Department of Psychiatry, 401 N. Quarry Rd., Stanford, CA 94305, United States of America; Veterans Affairs Palo Alto Health Care System, 795 Willow Rd., Menlo Park, CA 94025, United States of America.
| |
Collapse
|
39
|
Andrews CM, Pollack HA, Abraham AJ, Grogan CM, Bersamira CS, D'Aunno T, Friedmann PD. Medicaid coverage in substance use disorder treatment after the affordable care act. J Subst Abuse Treat 2019; 102:1-7. [PMID: 31202283 PMCID: PMC6578872 DOI: 10.1016/j.jsat.2019.04.002] [Citation(s) in RCA: 32] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2018] [Revised: 03/22/2019] [Accepted: 04/08/2019] [Indexed: 11/22/2022]
Abstract
The Affordable Care Act (ACA) prompted sweeping changes to Medicaid, including expanding insurance coverage to an estimated 12 million previously uninsured Americans, and imposing new parity requirements on benefits for behavioral health services, including substance use disorder treatment. Yet, limited evidence suggests that these changes have reduced the number of uninsured in substance use disorder treatment, or increased access to substance use disorder treatment overall. This study links data from a nationally-representative study of outpatient substance use disorder treatment programs and a unique national survey of state Medicaid programs to capture changes in insurance coverage among substance use disorder treatment patients after ACA implementation. Medicaid expansion was associated with a 15.7-point increase in the percentage of patients insured by Medicaid in substance use disorder treatment programs and a 13.7-point decrease in the percentage uninsured. Restrictions in state Medicaid benefits and utilization policies were associated with a decreased percentage of Medicaid patients in treatment. Moreover, Medicaid expansion was not associated with a change in the total number of clients served over the study period. Our findings highlight the important role Medicaid has played in increasing insurance coverage for substance use disorder treatment.
Collapse
Affiliation(s)
- Christina M Andrews
- College of Social Work, University of South Carolina, 1512 Pendleton St., Room 309, Columbia, SC 29208, United States of America.
| | - Harold A Pollack
- School of Social Service Administration, University of Chicago, 969 E. 60th St., Chicago, IL 60637, United States of America.
| | - Amanda J Abraham
- School of Public and International Affairs, University of Georgia, 204 Hall St., Athens, GA 30602, United States of America.
| | - Colleen M Grogan
- School of Social Service Administration, University of Chicago, 969 E. 60th St., Chicago, IL 60637, United States of America.
| | - Clifford S Bersamira
- Myron B. Thompson School of Social Work, University of Hawaii at Manoa, 2430 Campus Road, Honolulu, HI 96817, United States of America.
| | - Thomas D'Aunno
- Robert F. Wagner Graduate School of Public Service, New York University; 295 Lafayette St., #3062, New York, NY 10012, United States of America.
| | - Peter D Friedmann
- University of Massachusetts Medical School Baystate; 280 Chestnut St., Springfield, MA 01199, United States of America.
| |
Collapse
|
40
|
Abraham AJ, Smith BT, Andrews CM, Bersamira CS, Grogan CM, Pollack HA, Friedmann PD. Changes in State Technical Assistance Priorities and Block Grant Funds for Addiction After ACA Implementation. Am J Public Health 2019; 109:885-891. [PMID: 30998407 DOI: 10.2105/ajph.2019.305052] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
Objectives. To assess states' provision of technical assistance and allocation of block grants for treatment, prevention, and outreach after the expansion of health insurance coverage for addiction treatment in the United States under the Affordable Care Act (ACA). Methods. We used 2 waves of survey data collected from Single State Agencies in 2014 and 2017 as part of the National Drug Abuse Treatment System Survey. Results. The percentage of states providing technical assistance for cross-sector collaboration and workforce development increased. States also shifted funds from outpatient to residential treatment services. However, resources for opioid use disorder medications changed little. Subanalyses indicated that technical assistance priorities and allocation of funds for treatment services differed between Medicaid expansion and nonexpansion states. Public Health Implications. The ACA's infusion of new public and private funds enabled states to reallocate funds to residential services, which are not as likely to be covered by health insurance. The limited allocation of block grant funds for effective opioid medications is concerning in light of the opioid crisis, especially in states that did not implement the ACA's Medicaid expansion.
Collapse
Affiliation(s)
- Amanda J Abraham
- Amanda J. Abraham is with the School of Public and International Affairs, University of Georgia, Athens. Bikki Tran Smith, Colleen M. Grogan, and Harold A. Pollack are with the School of Social Service Administration, University of Chicago, Chicago, IL. Christina M. Andrews is with the College of Social Work, University of South Carolina, Columbia. Clifford S. Bersamira is with the Myron B. Thompson School of Social Work, University of Hawai'i at Mānoa, Honolulu. Peter D. Friedmann is with the University of Massachusetts Medical School Baystate, Springfield
| | - Bikki Tran Smith
- Amanda J. Abraham is with the School of Public and International Affairs, University of Georgia, Athens. Bikki Tran Smith, Colleen M. Grogan, and Harold A. Pollack are with the School of Social Service Administration, University of Chicago, Chicago, IL. Christina M. Andrews is with the College of Social Work, University of South Carolina, Columbia. Clifford S. Bersamira is with the Myron B. Thompson School of Social Work, University of Hawai'i at Mānoa, Honolulu. Peter D. Friedmann is with the University of Massachusetts Medical School Baystate, Springfield
| | - Christina M Andrews
- Amanda J. Abraham is with the School of Public and International Affairs, University of Georgia, Athens. Bikki Tran Smith, Colleen M. Grogan, and Harold A. Pollack are with the School of Social Service Administration, University of Chicago, Chicago, IL. Christina M. Andrews is with the College of Social Work, University of South Carolina, Columbia. Clifford S. Bersamira is with the Myron B. Thompson School of Social Work, University of Hawai'i at Mānoa, Honolulu. Peter D. Friedmann is with the University of Massachusetts Medical School Baystate, Springfield
| | - Clifford S Bersamira
- Amanda J. Abraham is with the School of Public and International Affairs, University of Georgia, Athens. Bikki Tran Smith, Colleen M. Grogan, and Harold A. Pollack are with the School of Social Service Administration, University of Chicago, Chicago, IL. Christina M. Andrews is with the College of Social Work, University of South Carolina, Columbia. Clifford S. Bersamira is with the Myron B. Thompson School of Social Work, University of Hawai'i at Mānoa, Honolulu. Peter D. Friedmann is with the University of Massachusetts Medical School Baystate, Springfield
| | - Colleen M Grogan
- Amanda J. Abraham is with the School of Public and International Affairs, University of Georgia, Athens. Bikki Tran Smith, Colleen M. Grogan, and Harold A. Pollack are with the School of Social Service Administration, University of Chicago, Chicago, IL. Christina M. Andrews is with the College of Social Work, University of South Carolina, Columbia. Clifford S. Bersamira is with the Myron B. Thompson School of Social Work, University of Hawai'i at Mānoa, Honolulu. Peter D. Friedmann is with the University of Massachusetts Medical School Baystate, Springfield
| | - Harold A Pollack
- Amanda J. Abraham is with the School of Public and International Affairs, University of Georgia, Athens. Bikki Tran Smith, Colleen M. Grogan, and Harold A. Pollack are with the School of Social Service Administration, University of Chicago, Chicago, IL. Christina M. Andrews is with the College of Social Work, University of South Carolina, Columbia. Clifford S. Bersamira is with the Myron B. Thompson School of Social Work, University of Hawai'i at Mānoa, Honolulu. Peter D. Friedmann is with the University of Massachusetts Medical School Baystate, Springfield
| | - Peter D Friedmann
- Amanda J. Abraham is with the School of Public and International Affairs, University of Georgia, Athens. Bikki Tran Smith, Colleen M. Grogan, and Harold A. Pollack are with the School of Social Service Administration, University of Chicago, Chicago, IL. Christina M. Andrews is with the College of Social Work, University of South Carolina, Columbia. Clifford S. Bersamira is with the Myron B. Thompson School of Social Work, University of Hawai'i at Mānoa, Honolulu. Peter D. Friedmann is with the University of Massachusetts Medical School Baystate, Springfield
| |
Collapse
|
41
|
Saloner B, Landis R, Stein BD, Barry CL. The Affordable Care Act In The Heart Of The Opioid Crisis: Evidence From West Virginia. Health Aff (Millwood) 2019; 38:633-642. [PMID: 30933592 PMCID: PMC7066526 DOI: 10.1377/hlthaff.2018.05049] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
West Virginia is at the epicenter of a national opioid crisis, with a 2016 fatal opioid overdose rate of 43.4 per 100,000 population-more than triple the US average. We used claims data for 2014-16 to examine trends in treatment for opioid use disorder (OUD) among people enrolled in the West Virginia Medicaid expansion program under the Affordable Care Act. Expanding Medicaid could provide services to populations that may previously have had limited access to OUD treatment. We thus sought to understand trends over time in OUD diagnosis and treatment, especially with medications. About 5.5 percent of all enrollees were diagnosed with OUD per year, and the monthly prevalence of OUD diagnoses nearly tripled during this three-year period. The ratio of people filling buprenorphine to the number diagnosed with OUD was around one-third in early 2014, increasing to more than 75 percent by late 2016. Mean annual duration of filled buprenorphine increased from 161 days in 2014 to 185 days in 2016, and most people filling buprenorphine also received counseling and drug testing during the study period. The growing use of medication treatment for OUD in the West Virginia Medicaid expansion population provides an opportunity to reduce overdose deaths.
Collapse
Affiliation(s)
- Brendan Saloner
- Brendan Saloner ( ) is an assistant professor in the Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health, in Baltimore, Maryland
| | - Rachel Landis
- Rachel Landis is a graduate student in public policy at George Washington University, in Washington, D.C
| | - Bradley D Stein
- Bradley D. Stein is a senior physician policy researcher at the RAND Corporation in Pittsburgh, Pennsylvania
| | - Colleen L Barry
- Colleen L. Barry is the Fred and Julie Soper Professor and chair of the Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health
| |
Collapse
|