Changes in Residential Substance Use Treatment Service Access Resulting From Recent Medicaid Section 1115 Waivers

The Effect of the Drug Medi-Cal Organized Delivery System 1115 Demonstration Waiver on Substance Use Disorder Treatment Access: Evidence from California

BACKGROUND

In August 2015, the California Department of Health Care Services created the Drug Medi-Cal Organized Delivery System 1115 demonstration waiver (DMC-ODS waiver) to improve service delivery to Medi-Cal-eligible individuals with a substance use disorder (SUD). We examine if implementing the DMC-ODS waiver across California counties improved patient access to SUD treatment services.

METHODS

We use administrative data from 2016 to 2020 from a reporting system for all publicly-funded SUD treatment services delivered in California and employ difference-in-differences and event study empirical strategies exploiting the differential timing of DMC-ODS waiver adoption across counties.

RESULTS

Event study analyses show that eleven or more months after the introduction of the DMC-ODS waiver, the number of unique patient admissions significantly increase by nearly 20%. Residential treatment admissions significantly increase by roughly 25% in all months post-waiver introduction.

CONCLUSIONS

This study provides valuable information for policymakers about implementing 1115 waivers, and the important public health implications. California's DMC-ODS waiver has demonstrated that 1115 waivers similar to it can likely increase access to SUD treatment.

Outpatient follow-up and use of medications for opioid use disorder after residential treatment among Medicaid enrollees in 10 states

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.

Association of facility characteristics and substance use disorder outcomes at discharge from residential treatment

INTRODUCTION

Individuals with substance use disorder (SUD) may benefit from services and supports delivered in residential settings. Prior research in this area has primarily focused on individual-level factors that affect outcomes, with little focus on the relationship between facility-level characteristics and treatment outcomes.

METHODS

Administrative data from 2713 individuals with an index enrollment in publicly funded residential treatment in Massachusetts during 2015 were linked with facility-level survey data from 33 treatment providers. This study conducted multilevel linear and logisitc regression analysis, adjusting for resident demographic, socioeconomic, and substance use history and severity, to examine relationships between facility-level characteristics, treatment duration and completion, and housing and employment status at discharge.

RESULTS

Residents stayed longer when they made and enforced rules (β = 30.22, p = 0.006). Residents were less likely to complete treatment as the number of non-clinical services increased (aOR = 0.918, p = 0.029), or in facilities where residents ate together family style (aOR = 0.485, p = 0.039). Being employed at discharge was more likely when house meetings were held less than once per week (aOR = 3.37, p = 0.005) and less likely when held more than once per week (aOR = 0.385, p = 0.038).

CONCLUSION

Overall, increased resident governance and fewer contingencies for successful treatment participation were associated with positive treatment outcomes. Future research should examine the internal processes of residential settings, including peer-to-peer interactions, to better understand how within-residence features affect outcomes.

Specialty Substance Use Disorder Treatment Admissions Steadily Increased In The Four Years After Medicaid Expansion

The Affordable Care Act's Medicaid expansion provided insurance coverage to many low-income adults with substance use disorders, but it is unclear whether this led to more people receiving treatment. We used the Treatment Episode Data Set and a difference-in-differences approach to compare annual rates of specialty treatment admissions in expansion versus nonexpansion states in the period 2010-17. We found that admissions to treatment steadily increased in the four years after Medicaid expansion, with 36 percent more people entering treatment by the fourth expansion year in expansion states compared to nonexpansion states. Changes were largest for people entering intensive outpatient programs and those seeking medication treatment for opioid use disorder. The share of admissions paid for by Medicaid increased 23 percentage points in expansion states compared to nonexpansion states, largely displacing treatment paid for by state and local governments. The gradual increase in specialty substance use disorder treatment admissions after Medicaid expansion may reflect improving capacity and access to care.