Insurance Financing Increased For Mental Health Conditions But Not For Substance Use Disorders, 1986–2014

The Long Arc of Substance Use Policy Innovation in Medicaid: Looking Back, Looking Forward

Policy Points The role of Medicaid in financing, organizing, and delivering substance use disorder (SUD) treatment has grown tremendously over time owing to expansions of eligibility and a push toward more uniformity in benefits. Current innovations in SUD treatment focus on expanding the delivery system to create a comprehensive continuum of care, using more value-based payment to reward quality care, and integrating SUD treatment with other systems (e.g., housing, employment, and the criminal legal system). Many of the promising innovations in delivery have not yet been rigorously studied, and implementation of effective models is often stymied because of the lack of flexibility in program requirements and variation in needs and resources across communities. Although policymakers can justifiably laud the great strides Medicaid has made in raising the standards for SUD treatment, there is a huge remaining gap in access to services amidst an unprecedented overdose crisis and looming turmoil in the program.

Telehealth Disparities in Outpatient Substance Use Disorder (SUD) Treatment among Medicaid Beneficiaries during COVID-19

BACKGROUND

We investigated racial and ethnic disparities in telehealth counseling among Medicaid-insured patients in outpatient substance use disorder (SUD) treatment clinics and assessed whether the clinic-level proportion of Medicaid-insured patients moderated these disparities.

METHODS

Using New York State (NYS) Medicaid and statewide treatment registry data, we analyzed 24,814 admission episodes across 399 outpatient SUD clinics during the first 6 months of COVID-19 (April-September 2020). Our outcome measure was the number of tele-counseling sessions within the first 90 days of treatment. Key independent variables included beneficiary race/ethnicity and the clinic-level proportion of Medicaid-insured patients, divided into four quartiles: lowest, second, third, and highest. Mixed effects negative binomial models assessed the associations between race/ethnicity, Medicaid proportions, and telehealth use, with interaction terms evaluating the moderating role of Medicaid proportions.

RESULTS

Black and Latinx patients received fewer telehealth sessions than non-Latinx White patients, with adjusted incidence rate ratios (aIRRs) of 0.86 (95% CI: 0.82, 0.91) for Black patients and 0.93 (95% CI: 0.88, 0.98) for Latinx patients. Black patients at clinics with the highest Medicaid proportions had higher telehealth usage rates compared to those at clinics with the lowest Medicaid proportions (aIRR, 1.20; 95% CI, 1.03-1.41). Patients in clinics with the highest Medicaid proportions were more likely to use individual telehealth counseling (aIRR, 1.02-1.88; 95% CI, 1.01-3.04).

CONCLUSIONS

Significant racial disparities in telehealth use exist, with variations persisting across clinics with different Medicaid proportions. Targeted interventions are needed to address these access gaps.

Disparities in Alcohol Treatment Use at the Intersection of Race, Ethnicity, Gender, and Insurance

BACKGROUND

Treatment for alcohol use disorder (AUD) has the potential to improve health and quality of life. Little is known about disparities in AUD treatment utilization at the intersection of race and gender. We examined disparities in AUD treatment utilization among those diagnosed with AUD in a community sample, by race, ethnicity, and gender, and whether disparities varied by insurance. We also examined whether criminal legal history and socioeconomic status moderated disparities in treatment.

METHODS

We used data from the nationally representative 2017 to 2019 National Survey on Drug Use and Health, the most recent 3-year period available. The analytic sample included noninstitutionalized adults aged 18 to 64 who met criteria for past year AUD and identified as White, Black, or Latinx (n = 7782). We examined disparities in AUD treatment utilization by race, ethnicity, and gender subgroup and by insurance status, estimating weighted logistic regressions, and adjusting for indicators of clinical need in concordance with the Institute of Medicine definition of healthcare disparity.

RESULTS

Only 5.4% of adults with AUD in the United States utilized AUD treatment in the past year. AUD treatment utilization did not significantly differ between White males and other racial, ethnic, and gender groups; however, we did identify disparities among Medicaid enrollees and those who were uninsured. Among Medicaid enrollees, Latinx females (3.2%) had lower treatment utilization than White males (9.3%, P < .05). Among uninsured individuals, Latinx males (1.8%) had lower treatment utilization than White males (6.2%, P < .05).

CONCLUSIONS

AUD treatment utilization was extremely low among adults in the United States aged 18 to 64 who met criteria for AUD. Ethnic and gender disparities in treatment utilization were revealed when examining differences in AUD treatment utilization by insurance status. Strategies for improving access to AUD treatment that address structural barriers to care are needed and should consider targeted approaches for Medicaid enrollees and those uninsured.

Survey of barriers and opportunities for prescribing buprenorphine for opioid use disorder in Alabama

Opioid-related overdose deaths have significantly increased in the USA and in Alabama. Despite this, medications for opioid use disorder (MOUD) remains significantly underutilized. Thus, this study aims to gain a better understanding of clinicians' viewpoints on potential barriers and opportunities that are likely to impact and improve the access to MOUD, especially buprenorphine prescribing. A cross-sectional survey study was conducted with Alabama's clinicians (n = 492). The survey containing a QR code was mailed to clinicians throughout the state and was asked about their viewpoints and thoughts on prescribing buprenorphine. Multivariable linear regression was used to examine associations between OUD self-efficacy, beliefs about the effectiveness of MOUD, attitudes regarding whether or not MOUD is addictive, and positive affect surrounding the treatment of OUD patients. A minority of respondents (39.8%) reported that they have an active X-waiver for MOUD. Results showed that beliefs that MOUD is addictive were significantly inversely correlated with beliefs about MOUD being effective. Furthermore, both self-efficacy and positive affect were significantly and positively associated with beliefs that MOUD is effective. Furthermore, nurse practitioners were more likely than physicians to have higher scores on the "MAT is Addictive" construct. Self-efficacy with OUD patients was positively associated with the "MOUD is Effective" construct. Finally, results showed that X-waivered providers expressed greater positive affect toward OUD patients than providers who were not X-waivered (b = 2.9, p < 0.001). Belief that MOUD is effective was also positively associated with higher scores on the positive affect construct (b = 0.5, p < 0.001). Several barriers and opportunities were identified in our survey data which could be used to explore MOUD expansion, especially buprenorphine prescribing. Strategic plans in expanding MOUD access may include educational trainings on MOUD, motivating clinicians to utilize their capacity by implementing incentive plans, increasing provider self-efficacy, reducing stigma around MOUD, and providing more financial support to uninsured patients.

The effects of behavioral health integration in Medicaid managed care on access to mental health and primary care services-Evidence from early adopters

OBJECTIVE

To evaluate the impacts of a transition to an "integrated managed care" model, wherein Medicaid managed care organizations moved from a "carve-out" model to a "carve-in" model integrating the financing of behavioral and physical health care.

DATA SOURCES/STUDY SETTING

Medicaid claims data from Washington State, 2014-2019, supplemented with structured interviews with key stakeholders.

STUDY DESIGN

This mixed-methods study used difference-in-differences models to compare changes in two counties that transitioned to financial integration in 2016 to 10 comparison counties maintaining carve-out models, combined with qualitative analyses of 15 key informant interviews. Quantitative outcomes included binary measures of access to outpatient mental health care, primary care, the emergency department (ED), and inpatient care for mental health conditions.

DATA COLLECTION

Medicaid claims were collected administratively, and interviews were recorded, transcribed, and analyzed using a thematic analysis approach.

PRINCIPAL FINDINGS

The transition to financially integrated care was initially disruptive for behavioral health providers and was associated with a temporary decline in access to outpatient mental health services among enrollees with serious mental illness (SMI), but there were no statistically significant or sustained differences after the first year. Enrollees with SMI also experienced a slight increase in access to primary care (1.8%, 95% CI 1.0%-2.6%), but no sustained statistically significant changes in the use of ED or inpatient services for mental health care. The transition to financially integrated care had relatively little impact on primary care providers, with few changes for enrollees with mild, moderate, or no mental illness.

CONCLUSIONS

Financial integration of behavioral and physical health in Medicaid managed care did not appear to drive clinical transformation and was disruptive to behavioral health providers. States moving towards "carve-in" models may need to incorporate support for practice transformation or financial incentives to achieve the benefits of coordinated mental and physical health care.

The United States must improve its data infrastructure to ensure high-quality mental health care

Use of and spending on mental health services in the United States more than doubled over the past two decades. In 2019, 19.2% of adults received mental health treatment (medications and/or counseling) at a cost of $135 billion. Yet, the United States has no data collection system to determine what proportion of the population benefited from treatment. Experts have for decades called for a learning behavioral health care system: a system that collects data on treatment services and outcomes to generate knowledge to improve practice. As the rates of suicide, depression, and drug overdoses in the United States continue to rise, the need for a learning health care system becomes even more pressing. In this paper, I suggest steps to move toward such a system. First, I describe the availability of data on mental health service use, mortality, symptoms, functioning, and quality of life. In the United States, the best sources of longitudinal information on mental health services received are Medicare, Medicaid, and private insurance claims and enrollment data. Federal and state agencies are starting to link these data to mortality information; however, these efforts need to be substantially expanded and include information on mental health symptoms, functioning, and quality of life. Finally, there must be greater efforts to make the data easier to access such as through standard data use agreements, online analytic tools, and data portals. Federal and state mental health policy leaders should be at the forefront of efforts to create a learning mental health care system.

Geographical Variations In Emergency Department Visits For Mental Health Conditions For Medicaid Beneficiaries

Despite Medicaid's importance as a payer and source of coverage for mental health care, relatively little is known about how prevalence, access, and quality might vary among Medicaid beneficiaries. This study used national Medicaid data from 2018 to assess regional variations in emergency department (ED) visits for mental health conditions, a measure that may reflect unmet needs for behavioral health care. We found substantial variations, with rates in the region with the highest visit rates eight times higher than those in the region with the lowest rates. Many regions with high rates of ED visits for mental health conditions also had high rates of outpatient mental health use. Regional patterns differed substantially, with some regions exhibiting high rates of ED visits related to anxiety but low rates for schizophrenia and vice versa. The presence of large variations in ED visits for mental health conditions, with substantial differences in the composition across regions, suggests a need for context-specific solutions, including assessments of the ways in which mental health benefits are structured at the state Medicaid agency level and of differences in provider accessibility and an understanding of the types of mental illness underlying high rates of use.

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

OBJECTIVE

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

DATA SOURCE

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

RESEARCH DESIGN

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

RESULTS

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

CONCLUSIONS

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

Substance Use Disorders Among Medicare Beneficiaries: Prevalence, Mental and Physical Comorbidities, and Treatment Barriers

INTRODUCTION

This study aimed to determine the prevalence of treated and untreated substance use disorders among Medicare beneficiaries, the characteristics of Medicare beneficiaries with substance use disorders, and reasons for their unmet needs.

METHODS

This study used data from the National Survey of Drug Use and Health, 2015-2019. Substance use disorder was defined based on DSM-IV dependence or abuse criteria. Descriptive analyses were conducted in 2021, including testing for differences in unadjusted means.

RESULTS

Approximately 1.7 million Medicare beneficiaries were estimated to have past-year substance use disorder (8% of Medicare beneficiaries aged <65 years and 2% aged ≥65 years). Overall, 77% had an alcohol use condition, 16% had a prescription drug use condition, and 10% had a marijuana use condition. Of those who had past-year substance use disorder, 11% received treatment for their condition. Common reasons for not receiving treatment were lack of motivation (41%), financial barriers (33%), concern about what others might think (24%), logistical barriers such as lack of transportation (21%), and uncertainty about treatment efficacy (13%). Medicare beneficiaries with substance use disorders were more than twice as likely to have past-year serious psychological distress as those without substance use disorders (44% vs 21%, p<0.001 for those aged <65 years; 14% vs 4%, p<0.001 for those aged ≥65 years). Percentages of past-year suicidal ideation were also much higher among Medicare beneficiaries with substance use disorders than without (24% vs 6%, p<0.001 for those aged <65 years; 7% vs 2%, p=0.006 for those aged ≥65 years).

CONCLUSIONS

Few Medicare beneficiaries who need substance use disorder treatment receive it. Reducing Medicare coverage gaps and stigma may help meet this need.

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

Importance

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

Objective

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

Design Setting and Participants

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

Exposures

Plan assignment.

Main Outcomes and Measures

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

Results

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

Conclusions and Relevance

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

Insurance barriers to substance use disorder treatment after passage of mental health and addiction parity laws and the affordable care act: A qualitative analysis

Introduction

People who use drugs (PWUDs) in the United States historically have had a higher probability of being uninsured. Passage of the Affordable Care Act, the Paul Wellstone and Pete Domenici Health Parity and Addiction Equity was expected to increase access to treatment for substance use disorder. Few studies to date have conducted qualitative research with substance use disorder (SUD) treatment providers regarding Medicaid and other insurance coverage of SUD treatment following passage of the ACA and parity laws. The present paper fills this gap by reporting data from in-depth interviews with treatment providers from three states, Connecticut, Kentucky, and Wisconsin, that differ in implementation of the ACA.

Methods

Study teams in each state conducted in-depth, semi-structured interviews with key informants who provided SUD treatment, including providers of behavioral health residential or outpatient programs, office-based buprenorphine providers and opioid treatment programs [OTP, i.e. methadone clinics] (n = 24 in Connecticut, n = 63 in Kentucky and n = 63 in Wisconsin). Key informants were asked for their perceptions on how Medicaid and private insurance facilitates or limits access to drug treatment. All interviews were transcribed verbatim and analyzed for key themes using MAXQDA software using a collaborative approach.

Results

Results from this study suggest that the promise of the ACA and parity laws to increase access to SUD treatment has only partially been realized. There is wide variation among the three states' Medicaid programs and among private insurance in the types of SUD treatment that is covered. Neither Kentucky's nor Connecticut's Medicaid covered methadone. Wisconsin Medicaid did not cover residential or intensive outpatient treatment. Thus, none of the states studied here provided all levels of care that the ASAM recommends for treating SUD. Further, there were several quantitative limits placed on SUD treatment such as number of urine drug screens or visits allowed. Providers complained that many treatments required prior authorizations, including MOUD like buprenorphine.

Conclusions

More reform is needed to make SUD treatment accessible to all who need it. Such reforms should consider defining standards for opioid use disorder treatment with reference to evidence-based practices, not be attempting parity with an arbitrarily defined medical standard.

National trends in non-fatal suicidal behaviors among adults in the USA from 2009 to 2017

BACKGROUND

The age-adjusted rate of suicide death in the USA has increased significantly since 2000 and little is known about national trends in non-fatal suicidal behaviors (ideation, plan, and attempt) among adults and their associated sociodemographic and clinical characteristics. This study examined trends in non-fatal suicidal behaviors among adults in the USA.

METHODS

Data were obtained from adults 18-65 years of age who participated in the National Survey on Drug Use and Health (NSDUH), including mental health assessment, from 2009 to 2017 (n = 335 359). Examinations of data involved trend analysis methods with the use of logistic regressions and interaction terms.

RESULTS

Suicidal ideation showed fluctuation from 2009 to 2017, whereas suicide plan and attempt showed significantly positive linear trends with the odds increasing by an average of 3% and 4%, respectively. Suicide plan increased the most for females and adults ages 18-34, and attempt increased the most for adults with drug dependence. Both plan and attempt increased the most among adults who either had mental illness but were not in treatment or had no mental illness.

CONCLUSIONS

Given attempted suicide is the strongest known risk factor for suicide death, reducing non-fatal suicidal behaviors including attempt are important public health and clinical goals. The interactional findings of age, sex, mental health status, and drug dependence point toward the importance of tailoring prevention efforts to various sociodemographic and clinical factors.

The consequences of Medicaid expansion under the Affordable Care Act for police arrests

BACKGROUND & METHODS

National protests in the summer of 2020 drew attention to the significant presence of police in marginalized communities. Recent social movements have called for substantial police reforms, including "defunding the police," a phrase originating from a larger, historical abolition movement advocating that public investments be redirected away from the criminal justice system and into social services and health care. Although research has demonstrated the expansive role of police to respond a broad range of social problems and health emergencies, existing research has yet to fully explore the capacity for health insurance policy to influence rates of arrest in the population. To fill this gap, we examine the potential effect of Medicaid expansion under the Affordable Care Act (ACA) on arrests in 3,035 U.S. counties. We compare county-level arrests using FBI Uniform Crime Reporting (UCR) Program Data before and after Medicaid expansion in 2014-2016, relative to counties in non-expansion states. We use difference-in-differences (DID) models to estimate the change in arrests following Medicaid expansion for overall arrests, and violent, drug, and low-level arrests.

RESULTS

Police arrests significantly declined following the expansion of Medicaid under the ACA. Medicaid expansion produced a 20-32% negative difference in overall arrests rates in the first three years. We observe the largest negative differences for drug arrests: we find a 25-41% negative difference in drug arrests in the three years following Medicaid expansion, compared to non-expansion counties. We observe a 19-29% negative difference in arrests for violence in the three years after Medicaid expansion, and a decrease in low-level arrests between 24-28% in expansion counties compared to non-expansion counties. Our main results for drug arrests are robust to multiple sensitivity analyses, including a state-level model.

CONCLUSIONS

Evidence in this paper suggests that expanded Medicaid insurance reduced police arrests, particularly drug-related arrests. Combined with research showing the harmful health consequences of chronic policing in disadvantaged communities, greater insurance coverage creates new avenues for individuals to seek care, receive treatment, and avoid criminalization. As police reform is high on the agenda at the local, state, and federal level, our paper supports the perspective that broad health policy reforms can meaningfully reduce contact with the criminal justice system under historic conditions of mass criminalization.

Use of Electronic Health Information Technology in a National Sample of Hospitals That Provide Specialty Substance Use Care

OBJECTIVE

Most U.S. acute care hospitals have adopted basic electronic health record (EHR) functionality and health information exchange (HIE) (84% and 88%, respectively, in 2017). This study examined whether rates of EHR and HIE adoption by hospital-based substance use disorder programs are lower than rates by acute care hospitals.

METHODS

Data from the 2017 National Survey on Substance Abuse Treatment Services were analyzed to examine adoption of basic EHR functionality (i.e., assessment, progress monitoring, discharge, labs, and prescription dispensing) and use of HIE by hospital-based programs. Analyses used weighted multivariable models of EHR and HIE outcomes, adjusted for nonresponse.

RESULTS

Of 894 hospital-based substance use disorder programs with EHR information, two-thirds (N=606, 68%) reported use of basic EHR functionality. Psychiatric hospitals were less likely than acute care hospitals to have adopted EHR (odds ratio [OR]=0.49, 95% confidence interval [CI]=0.35-0.71). Compared with nonprofit hospitals, for-profit (OR=0.23, 95% CI=0.16-0.35) and government-owned (OR=0.52, 95% CI=0.33-0.83) hospitals were less likely to use basic EHR functionality. Hospital-based programs providing medications for alcohol or opioid use disorders were more likely than those not providing such medications to use basic EHR (OR=1.95, 95% CI=1.31-2.90). Of 839 hospitals with information on HIE use, 598 (71%) reported using electronic HIE. Adoption of basic EHR functionality was the strongest predictor of HIE use (OR=4.73, 95% CI=3.29-6.79).

CONCLUSIONS

Hospital-based substance use disorder programs trail behind U.S. acute care hospitals in adoption of basic EHR and electronic HIE. Findings raise concerns about missed opportunities to improve hospital-based substance use disorder care quality and performance measurement.

Use of behavioral health care in Medicaid managed care carve-out versus carve-in arrangements

OBJECTIVE

To evaluate differences in access to behavioral health services for Medicaid enrollees covered by a Medicaid entity that integrated the financing of behavioral and physical health care ("carve-in group") versus a Medicaid entity that separated this financing ("carve-out group").

DATA SOURCES/STUDY SETTING

Medicaid claims data from two Medicaid entities in the Portland, Oregon tri-county area in 2016.

STUDY DESIGN

In this cross-sectional study, we compared differences across enrollees in the carve-in versus carve-out group, using a machine learning approach to incorporate a large set of covariates and minimize potential selection bias. Our primary outcomes included behavioral health visits for a variety of different provider types. Secondary outcomes included inpatient, emergency department, and primary care visits.

DATA COLLECTION

We used Medicaid claims, including adults with at least 9 months of enrollment.

PRINCIPAL FINDINGS

The study population included 45,786 adults with mental health conditions. Relative to the carve-out group, individuals in the carve-in group were more likely to access outpatient behavioral health (2.39 percentage points, p < 0.0001, with a baseline rate of approximately 73%). The carve-in group was also more likely to access primary care physicians, psychologists, and social workers and less likely to access psychiatrists and behavioral health specialists. Access to outpatient behavioral health visits was more likely in the carve-in arrangement among individuals with mild or moderate mental health conditions (compared to individuals with severe mental illness) and among black enrollees (compared to white enrollees).

CONCLUSIONS

Financial integration of physical and behavioral health in Medicaid managed care was associated with greater access to behavioral health services, particularly for individuals with mild or moderate mental health conditions and for black enrollees. Recent changes to incentivize financial integration should be monitored to assess differential impacts by illness severity, race and ethnicity, provider types, and other factors.

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.

Association between availability of medications for opioid use disorder in specialty treatment and use of medications among patients: A state-level trends analysis

INTRODUCTION

Access to medication for opioid use disorder (MOUD) is a recognized public health challenge to improving the health of people with opioid use disorder (OUD) in many communities. Prior studies have shown that although MOUD availability has increased over time, particularly in some states, many substance use treatment facilities still do not offer medications. The relationship between greater availability of MOUD and use of MOUD among patients in treatment programs is not well understood.

METHODS

We used the National Survey of Substance Abuse Treatment Services to calculate the percent of specialty facilities per state providing MOUD from 2007 to 2018 and the Treatment Episode Data Set-Admissions (TEDS-A) to estimate the likelihood that a patient would have MOUD as part of their treatment plan during the same time period. We estimated models with patient-level TEDS-A data as the outcome and state-aggregated one-year lagged availability of MOUD in facilities as the main predictor, stratifying by treatment facility type (intensive outpatient, non-intensive outpatient, and residential).

RESULTS

We found that increasing MOUD availability at the facility level was associated with increased MOUD use in non-intensive and residential facilities at the patient level. Specifically, a 10 percentage point increase in MOUD availability was associated with a 4.5 percentage point increase in MOUD use among patients of non-intensive outpatient facilities (p-value = 0.03), and a 2.5 percentage points increase in residential facilities (p-value = 0.02). Non-Whites and patients in the Northeast had greater likelihoods of increased MOUD use in response to increased availability by facilities.

CONCLUSION

Increasing MOUD availability among specialty treatment facilities is likely to promote better access to MOUD for patients seeking treatment for OUD.

Characterizing Emotional State Transitions During Prolonged Use of a Mindfulness and Meditation App: Observational Study

BACKGROUND

The increasing demand for mental health care, a lack of mental health care providers, and unequal access to mental health care services have created a need for innovative approaches to mental health care. Digital device apps, including digital therapeutics, that provide recommendations and feedback for dealing with stress, depression, and other mental health issues can be used to adjust mood and ultimately show promise to help meet this demand. In addition, the recommendations delivered through such apps can also be tailored to an individual's needs (ie, personalized) and thereby potentially provide greater benefits than traditional "one-size-fits-all" recommendations.

OBJECTIVE

This study aims to characterize individual transitions from one emotional state to another during the prolonged use of a digital app designed to provide a user with guided meditations based on their initial, potentially negative, emotional state. Understanding the factors that mediate such transitions can lead to improved recommendations for specific mindfulness and meditation interventions or activities (MMAs) provided in mental health apps.

METHODS

We analyzed data collected during the use of the Stop, Breathe & Think (SBT) mindfulness app. The SBT app prompts users to input their emotional state before and immediately after engaging with MMAs recommended by the app. Data were collected from more than 650,000 SBT users engaging in nearly 5 million MMAs. We limited the scope of our analysis to users with 10 or more MMA sessions that included at least 6 basal emotional state evaluations. Using clustering techniques, we grouped emotions recorded by individual users and then applied longitudinal mixed effect models to assess the associations between individual recommended MMAs and transitions from one group of emotions to another.

RESULTS

We found that basal emotional states have a strong influence on transitions from one emotional state to another after MMA engagement. We also found that different MMAs impact these transitions, and many were effective in eliciting a healthy transition but only under certain conditions. In addition, we observed gender and age effects on these transitions.

CONCLUSIONS

We found that the initial emotional state of an SBT app user determines the type of SBT MMAs that will have a favorable effect on their transition from one emotional state to another. Our results have implications for the design and use of guided mental health recommendations for digital device apps.

Do expansions in adolescent access to public insurance affect the decisions of substance use disorder treatment providers?

We apply a mixed-payer economy model to study the effects of changes in the generosity of children's public health insurance programs - measured by Medicaid and Children's Health Insurance Program income thresholds - on substance use disorder (SUD) treatment provider behavior. Using government data on specialty SUD treatment providers over the period 1997-2011 combined with a two-way fixed-effects model and local event study, we show that increases in the generosity of children's public health insurance induce providers to participate in some, but not all, public markets. Our effects appear to be driven by non-profit and government providers. Non-profit providers also appear to increase treatment quantity slightly in response to coverage expansions.

The Relationship Between State Mental Health Agency and Medicaid Spending with Outcomes

Little is known about relationships between state mental health expenditures and outcomes. This analysis evaluated relationships between spending and income across the states and mental health outcomes. Relationships between state per capita SMHA and Medicaid mental health spending, as well as median household income, percent of residents on Medicaid and Mental Health America (MHA) ranking, suicide and incarceration rates were assessed using correlations and multiple regressions. Median household income predicted MHA overall and youth ranking. Per capita Medicaid mental health spending predicted MHA prevalence ranking. Median household income and Medicaid spending predicted access to care ranking and incarcerations. Median income, Medicaid spending and percent receiving Medicaid predicted suicide rate. The findings suggest median household income may, in some cases, predict mental health treatment quality and outcomes more strongly than spending. However, the relationship with per capita mental health Medicaid spending on outcomes is also noteworthy.

Institutions For Mental Diseases Medicaid Waivers: Impact On Payments For Substance Use Treatment Facilities

The Institutions for Mental Diseases (IMD) exclusion prohibits use of federal Medicaid funds to treat enrollees ages 21-64 in psychiatric residential treatment facilities that have more than sixteen beds. In 2015 the federal government created a streamlined application pathway for state waivers of this rule to allow Medicaid coverage for substance use disorder (SUD) treatment in residential facilities. Nine states received IMD waivers during the period 2015-18. Using data from the 2010-18 National Survey of Substance Abuse Treatment Services, we examined changes in residential and outpatient SUD treatment facilities' acceptance of Medicaid and other types of health coverage, as well as self-pay arrangements and provision of charity care, after states' adoption of IMD waivers. Acceptance of Medicaid increased 34 percent at residential treatment facilities and 9 percent at intensive outpatient facilities two years after waiver implementation. Delivery of medications for opioid use disorder did not increase in residential facilities post waiver but did increase to some extent in outpatient facilities. Our findings suggest that IMD waivers may be an important tool for advancing access to a full continuum of SUD treatment for Medicaid enrollees.

Rural-Nonrural Differences in Telemedicine Use for Mental and Substance Use Disorders Among Medicaid Beneficiaries

OBJECTIVE

This study investigated recent rural-nonrural trends in the prevalence and amount of mental and substance use disorder telemedicine received by adult Medicaid beneficiaries.

METHODS

An analysis of 2012-2017 claims data from the IBM MarketScan Multi-State Medicaid Database for adult beneficiaries ages 18-64 years with mental and substance use disorder diagnoses (N= 1,603,066) identified telemedicine services by using procedure modifier codes and ICD-9 and ICD-10 diagnosis codes. Unadjusted trends in telemedicine use were examined, and multivariate regression models compared the prevalence and amount of telemedicine and in-person outpatient treatment received by rural (N=428,697) and nonrural (N= 1,174,369) beneficiaries and by diagnosis.

RESULTS

Rates of telemedicine treatment for mental and substance use disorders among Medicaid beneficiaries increased during the study period but remained low. Among rural beneficiaries, there was a 5.9 percentage point increase in telemedicine for mental disorders and a 1.9 percentage point increase in telemedicine for substance use disorders. After control for other individual characteristics, rural beneficiaries were more likely than nonrural beneficiaries to receive any telemedicine for mental disorder (2.2 percentage points more likely) or substance use disorder (0.6 percentage points) treatment. Receipt of telemedicine was associated with receipt of more in-person outpatient services by rural beneficiaries (11.2 more visits for mental disorders and 8.2 more for substance use disorders).

CONCLUSIONS

Although provision of telemedicine for mental and substance use disorders increased during the study period and was somewhat more common among rural Medicaid beneficiaries, it remains an underused resource for addressing care shortages in rural areas.

Increasing Access to Opioid Use Disorder Treatment: Assessing State Policies and the Evidence Behind Them

OBJECTIVE

Combatting the opioid epidemic requires systemic policy changes that address the underutilization of medication-assisted treatment, a therapy that is effective in treating opioid use disorder. In this study, we present approaches used in five states to increase medication-assisted treatment financing and access.

METHOD

We conducted case studies in five U.S. states, interviewing key informants and reviewing the published literature and unpublished documents.

RESULTS

In these states, Medicaid expansion was the most significant lever available to expand financing and access to medication-assisted treatment. Other key levers include Medicaid Section 1115 SUD demonstrations, State Targeted Response to the Opioid Crisis and State Opioid Response grants, state contracting mechanisms, and other state regulations.

CONCLUSIONS

States in this study reported substantial progress in increasing access to medication-assisted treatment, but empirical evidence of their effects is still emerging.

Changes in Medicaid Acceptance by Substance Abuse Treatment Facilities After Implementation of Federal Parity

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.

Assessing an Epidemic: Utility of the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition Level 2 Substance Use Screener in Adult Psychiatric Inpatients

BACKGROUND

Inpatient psychiatric hospitals provide an important point of care for assessing and stabilizing substance use and for facilitating linkage to appropriate treatment. Toxicology screening provides a key measure of substance use yet may miss many cases of substance use because of variable windows of detection and the limited scope of substances assessed. This study assesses the utility of the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) Level 2 Substance Use screener as a supplemental tool for identifying substance use by self-report within an inpatient psychiatric hospital setting.

METHODS

From a larger sample of 97 adult psychiatric inpatients, 60 who underwent drug toxicology testing and completed the DSM-5 screener were assessed. We examined the sensitivity and specificity of the self-report screener in comparison with drug toxicology test results collected by chart review.

RESULTS

Sensitivity of the DSM-5 screener varied across substances assessed: The self-report measure identified 100% of individuals who tested positive for opioid use, 83% who tested positive for cannabis use, 50% who tested positive for cocaine use, and 37% who tested positive for benzodiazepine use. The self-report measure also identified 27 instances among 60 participants in which substance use identified by self-report was not detected by toxicology testing.

CONCLUSION

The brief and easily administered DSM-5 Level 2 Substance Use screener shows promise for improving identification of substance use in an inpatient psychiatric hospital setting. This measure may also provide psychiatric inpatient nursing staff with a means of working collaboratively with patients to assess substance use and coordinate appropriate treatment plans.

Evaluating the role of Section 1115 waivers on Medicaid coverage and utilization of opioid agonist therapy among substance use treatment admissions

OBJECTIVE

To examine the impact of Section 1115 waivers on Medicaid coverage and opioid agonist therapy (OAT) utilization among substance use treatment admissions.

DATA SOURCE

Treatment Episode Data Set-Admissions (TEDS-A) (2001-2012).

STUDY DESIGN

We examined effects of 1115 waiver implementation on proportions of substance use treatment admissions with Medicaid and receiving OAT, using random intercept linear regression.

PRINCIPAL FINDINGS

1115 waiver implementation was associated with an average of a 6 percentage point increase in proportion of all admissions with Medicaid, and 4 percentage point increase among opioid outpatient admissions. Implementation was not associated with change in proportion of opioid outpatient admissions receiving OAT.

CONCLUSIONS

1115 waivers influence Medicaid coverage among substance use treatment admissions. The findings improve our understanding of how state policies impact substance use treatment utilization.

Medication Treatment For Opioid Use Disorders In Substance Use Treatment Facilities

Medication treatment (MT) is one of the few evidence-based strategies proposed to combat the current opioid epidemic. We examined national trends and correlates of offering MT in substance use treatment facilities in the United States. According to data from national surveys, the proportion of these facilities that offered any MT increased from 20.0 percent in 2007 to 36.1 percent in 2016-mainly the result of increases in offering buprenorphine and extended-release naltrexone. Only 6.1 percent of facilities offered all three MT medications in 2016. Facilities in states with higher opioid overdose death rates, facilities that accepted health insurance overall (and, more specifically, those that accepted Medicaid in states that opted to expand eligibility for Medicaid), and facilities in states with more comprehensive coverage of MT under their Medicaid plans had higher odds of offering MT. The findings highlight the persistent unmet need for MT nationally and the role of expansion of health insurance in the dissemination of these treatments.

Mental Health Parity and Addiction Equity Act and the Use of Outpatient Behavioral Health Services in the United States, 2005-2016

Objectives. To assess the impact of the 2008 Paul Wellstone and Pete Domenici Mental Health Parity and Addiction Equity Act (MHPAEA) on mental and substance use disorder services in the private, large group employer-sponsored insurance market in the United States. Methods. We analyzed data from the IBM MarketScan Commercial Database from January 2005 through September 2015 by using population-level interrupted time series regressions to determine whether parity implementation was associated with utilization and spending outcomes. Results. MHPAEA had significant positive associations with utilization of mental and substance use disorder outpatient services. A spending decomposition analysis indicated that increases in utilization were the primary drivers of increases in spending associated with MHPAEA. Analyses of opioid use disorder and nonopioid substance use disorder services found that associations with utilization and spending were not attributable only to increases in treatment of opioid use disorder. Conclusions. MHPAEA is positively associated with utilization of outpatient mental and substance use disorder services for Americans covered by large group employer-sponsored insurance. Public Health Implications. These trends continued over the 5-year post-MHPAEA period, underscoring the long-term relationship between this policy change and utilization of behavioral health services.

Behavioral Health Integration With Primary Care: Implementation Experience and Impacts From the State Innovation Model Round 1 States

Policy Points Individuals with behavioral health (BH) conditions comprise a medically complex population with high costs and high health care needs. Considering national shortages of BH providers, primary care providers serve a critical role in identifying and treating BH conditions and making referrals to BH providers. States are increasingly seeking ways to address BH conditions among their residents. States funded by the Centers for Medicare and Medicaid Services under the first round of the State Innovation Models (SIM) Initiative all invested in BH integration. States found sharing data among providers, bridging professional divides, and overcoming BH provider shortages were key barriers. Nonetheless, states made significant strides in integrating BH care. Beyond payment models, a key catalyst for change was facilitating informal relationships between BH providers and primary care physicians. Infrastructure investments such as promoting data sharing by connecting BH providers to a health information exchange and providing tailored technical assistance for both BH and primary care providers were also important in improving integration of BH care.

CONTEXT

Increasing numbers of states are looking for ways to address behavioral health (BH) conditions among their residents. The first round of the State Innovation Models (SIM) Initiative provided financial and technical support to six states since 2013 to test the ability of state governments to lead health care system transformation. All six SIM states invested in integration of BH and primary care services. This study summarizes states' progress, challenges, and lessons learned on BH integration. Additionally, the study reports impacts on expenditure, utilization, and quality-of-care outcomes for persons with BH conditions across four SIM states.

METHODS

We use a mixed-methods design, drawing on focus groups and key informant interviews to reach conclusions on implementation and quantitative analysis using Medicaid claims data to assess impact. For three Medicaid accountable care organization (ACO) models funded under SIM, we used a difference-in-differences regression model to compare outcomes for model participants with BH conditions and an in-state comparison group before-and-after model implementation. For the behavioral health home (BHH) model in Maine, we used a pre-post design to assess how outcomes for model participants changed over time.

FINDINGS

Informal relationship building, tailored technical assistance, and the promotion of data sharing were key factors in making progress. After three years of implementation, the growth in total expenditures was less than the comparison group by $128 (-$253, -$3; p < 0.10) and $62 (-$87, -$36; p < 0.001) per beneficiary per month for beneficiaries with BH conditions attributed to an ACO in Minnesota and Vermont, respectively. Likewise, there were reductions in emergency department use for ACO participants in all three states after two to four years of implementation. However, there was no improvement in BH-related quality metrics for ACO beneficiaries in all three states. Although participants in the BHH model had increased expenditures after two years of implementation, use of primary care and specialty care services increased by 3% and 8%, respectively, and antidepressant medication adherence also improved.

CONCLUSIONS

The SIM Round 1 states made considerable progress in integrating BH and primary care services, and there were promising findings for all models. Taken together, there is some evidence that Medicaid payment models can improve patterns of care for beneficiaries with BH conditions.

The effect of referral to expedited Medicaid on substance use treatment utilization among people with serious mental illness released from prison

Adults released from incarceration are at high risk of death from drug-related causes, pointing to the importance of connecting individuals to healthcare services after release from prison. Though Medicaid plays an important role in financing behavioral health treatments for vulnerable groups, many states terminate individuals' Medicaid coverage during incarceration. A significant risk factor for substance use disorders (SUD) among incarcerated individuals is serious mental illness (SMI). In January 2006, Washington State began a program of expedited Medicaid enrollment for individuals with mental illnesses being discharged from state prisons, jails, and psychiatric hospitals. Prior literature has shown this program to be effective in increasing Medicaid enrollment and use of mental health services for people with SMI. The current paper examined the effect of referral to expedited Medicaid on use of SUD treatment for people with SMI released from prison. Our sample consisted of 3086 individuals with a diagnosis of SMI who were released from prison from January 1, 2006 to December 31, 2007. Of the sample we identified, 871 individuals received referrals for expedited Medicaid and 2215 did not. To control for selection bias on observed characteristics for referral, we used inverse probability weights (IPW) to balance the referred and not-referred groups on more than 50 baseline covariates. We used doubly-robust IPW models to estimate the effect of referral to expedited Medicaid on use of SUD treatments following prison release. Approximately 12% of our sample used any SUD treatment by 3 months after release, with this percentage rising to 28% at 12 months. When controlling for baseline differences, referral to expedited Medicaid enrollment was associated on average with a 6.7 (SE 2.9, p < .05) percentage point increase in the predicted probability of using any SUD treatment in the 3 months following release as compared to those not referred to the program. This effect size represents a 61% increase in the probability of using any treatment by 3 months. The result was similar for the 6-month follow-up period and persisted at the 12-month follow-up though the magnitude of the effect decreased somewhat. Overall, our results suggest that expedited Medicaid enrollment for people with SMI released from prison can increase use of SUD services.

Do naloxone access laws increase outpatient naloxone prescriptions? Evidence from Medicaid

BACKGROUND

Naloxone is a prescription medication that can quickly and effectively reverse opioid overdose. Medicaid is a major payer of substance use disorder services, and Medicaid beneficiaries experience especially high rates of opioid overdose. As opioid overdose rates have risen sharply, every state has modified its laws to make naloxone easier to access. The aim of this paper is to determine whether implementation of different provisions of naloxone access laws led to increased naloxone dispensing financed by Medicaid.

METHODS

We reviewed naloxone legislation passed by every state between 2007 and 2016. We used the Medicaid State Drug Utilization dataset to examine the effect of different types of state naloxone access law provisions, separately and as a whole, on the number of outpatient naloxone prescriptions reimbursed by Medicaid from 2007 to 2016. We included state-level covariates in our models that may be correlated with naloxone utilization in Medicaid and passage of naloxone access laws.

RESULTS

We found that the presence of any naloxone law was significantly associated with increases in outpatient naloxone reimbursed through Medicaid. Laws containing standing order provisions were most consistently associated with increases in naloxone dispensing across models. Standing order provisions led on average to an increase of approximately 33 naloxone prescriptions per state-quarter, which is equivalent to 74% of the average number of naloxone prescriptions per state-quarter.

CONCLUSIONS

Naloxone access laws, particularly those with standing order provisions, appear to be an effective policy approach to increasing naloxone access among Medicaid beneficiaries.

National Trends In Specialty Outpatient Mental Health Care Among Adults

We examined national trends in the receipt of specialty outpatient mental health care, using data for 2008-15 from the National Survey on Drug Use and Health. Between 2008-09 and 2014-15 the number of US adults who received outpatient mental health care in the specialty sector rose from 11.3 million to 13.7 million per year, representing an increase from 5.0 percent to 5.7 percent of the adult population. Among those recipients, however, the annual weighted mean number of visits to the specialty sector remained unchanged. We found increases in both numbers and percentages of adults who received care within the specialty sector across age and sex groups and among non-Hispanic whites, people with Medicare, people with private health insurance, and people with family incomes of $20,000-$49,999. Increases in receipt of specialty mental health care during 2012-15 may be related to recent policy initiatives aimed at reducing financial barriers to care.

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

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

The Affordable Care Act and the Faltering Revolution in Behavioral Health Care

Often described in such terms as a "revolution" and a "game-changer" for the behavioral health sector in the United States, the Affordable Care Act has helped to enhance coverage for mental health and substance use disorders while encouraging service system innovations at the organizational level. However, tens of millions of Americans still lack health insurance, insurance companies are resisting the implementation of parity coverage rules, and inequalities in the financing and organization of care continue to worsen in key respects. This article examines these difficulties and their political-economic nature, highlighting the need for a single-payer framework if the task of reform is to be fulfilled.

National Trends in the Prevalence of Suicidal Ideation and Behavior Among Young Adults and Receipt of Mental Health Care Among Suicidal Young Adults

OBJECTIVE

This study examined national trends in the prevalence of suicidal ideation and behavior among young adults and receipt of mental health care among suicidal young adults.

METHOD

We examined restricted data from 145,800 persons aged 18 to 25 years who participated in the 2009 to 2015 National Surveys on Drug Use and Health. Descriptive analyses and bivariable and multivariable logistic regressions were applied.

RESULTS

Among US young adults during 2009 to 2015, the 12-month prevalence of suicidal ideation increased from 6.1% to 8.3%, the 12-month prevalence of suicide plan increased from 2.0% to 2.7%, and 12-month prevalence of suicide attempt increased from 1.1% to 1.6%. After adjusting for personal factors and changes in residing county's population characteristics, we found upward trends in suicidal ideation among non-Hispanic whites and Hispanics, an upward trend in suicide plan among young adults overall, and an upward trend in suicide attempt among those without major depressive episodes (MDE). Among young adults with MDE, the prevalence of suicide attempt remained high and unchanged. During 2009 to 2015, trends in receipt of mental health care remained unchanged among most suicidal young adults and declined slightly among uninsured suicidal young adults. The annual average prevalence of receipt of mental health care was 36.2% among suicidal young adults.

CONCLUSION

During 2009 to 2015, suicidal ideation, suicide plan, and suicide attempt increased among young adults overall, but receipt of mental health care among suicidal young adults did not increase. Our results suggest that effective efforts are needed for suicide prevention and promotion of mental health care among young adults.

Access to Health Insurance and Utilization of Substance Use Disorder Treatment: Evidence from the Affordable Care Act Dependent Coverage Provision

The relationship between insurance coverage and use of specialty substance use disorder (SUD) treatment is not well understood. In this study, we add to the literature by examining changes in admissions to SUD treatment following the implementation of a 2010 Affordable Care Act provision requiring health insurers to offer dependent coverage to young adult children of their beneficiaries under age 26. We use national administrative data on admissions to specialty SUD treatment and apply a difference-in-differences design to study effects of the expansion on the rate of treatment utilization among young adults and, among those in treatment, changes in insurance status and payment source. We find that admissions to treatment declined by 11% after the expansion. However, the share of young adults covered by private insurance increased by 5.4 percentage points and the share with private insurance as the payment source increased by 3.7 percentage points. This increase was largely offset by decreased payment from government sources. Copyright © 2017 John Wiley & Sons, Ltd.

Medications for substance use disorders (SUD): emerging approaches

INTRODUCTION

Substance use disorders are a group of chronic relapsing disorders of the brain, which have massive public health and societal impact. In some disorders (e.g., heroin/prescription opioid addictions) approved medications have a major long-term benefit. For other substances (e.g., cocaine, amphetamines and cannabis) there are no approved medications, and for alcohol there are approved treatments, which are not in wide usage. Approved treatments for tobacco use disorders are available, and novel medications are also under study. Areas covered: Medication-based approaches which are in advanced preclinical stages, or which have reached proof-of concept clinical laboratory studies, as well as clinical trials. Expert opinion: Current challenges involve optimizing translation between preclinical and clinical development, and between clinical laboratory studies to therapeutic clinical trials. Comorbidities including depression or anxiety are challenges for study design and analysis. Improved pharmacogenomics, biomarker and phenotyping approaches are areas of interest. Pharmacological mechanisms currently under investigation include modulation of glutamatergic, GABA, vasopressin and κ-receptor function, as well as inhibition of monoamine re-uptake. Other factors that affect potential market size for emerging medications include stigma, availability of treatment settings, adoption by clinicians, and the prevalence of persons with SUD who are not actively treatment-seeking.

Association of Cost Sharing With Mental Health Care Use, Involuntary Commitment, and Acute Care

IMPORTANCE

A higher out-of-pocket price for mental health care may lead not only to cost savings but also to negative downstream consequences.

OBJECTIVE

To examine the association of higher patient cost sharing with mental health care use and downstream effects, such as involuntary commitment and acute mental health care use.

DESIGN, SETTING, AND PARTICIPANTS

This difference-in-differences study compared changes in mental health care use by adults, who experienced an increase in cost sharing, with changes in youths, who did not experience the increase and thus formed a control group. The study examined all 2 780 558 treatment records opened from January 1, 2010, through December 31, 2012, by 110 organizations that provide specialist mental health care in the Netherlands. Data analysis was performed from January 18, 2016, to May 9, 2017.

EXPOSURES

On January 1, 2012, the Dutch national government increased the out-of-pocket price of mental health services for adults by up to €200 (US$226) per year for outpatient treatment and €150 (US$169) per month for inpatient treatment.

MAIN OUTCOMES AND MEASURES

The number of treatment records opened each day in regular specialist mental health care, involuntary commitment, and acute mental health care, and annual specialist mental health care spending.

RESULTS

This study included 1 448 541 treatment records opened from 2010 to 2012 (mean [SD] age, 41.4 [16.7] years; 712 999 men and 735 542 women). The number of regular mental health care records opened for adults decreased abruptly and persistently by 13.4% (95% CI, -16.0% to -10.8%; P < .001) per day when cost sharing was increased in 2012. The decrease was substantial and significant for severe and mild disorders and larger in low-income than in high-income neighborhoods. Simultaneously, in 2012, daily record openings increased for involuntary commitment by 96.8% (95% CI, 87.7%-105.9%; P < .001) and for acute mental health care by 25.1% (95% CI, 20.8%-29.4%; P < .001). In contrast to our findings for adults, the use of regular care among youths increased slightly and the use of involuntary commitment and acute care decreased slightly after the reform. Overall, the cost-sharing reform was associated with estimated savings of €13.4 million (US$15.1 million). However, for adults with psychotic disorder or bipolar disorder, the additional costs of involuntary commitment and acute mental health care exceeded savings by €25.5 million (US$28.8 million).

CONCLUSIONS AND RELEVANCE

Higher cost sharing for seriously ill and low-income patients could discourage treatment of vulnerable populations and create substantial downstream costs.

Promoting Adoption of Medication for Opioid and Alcohol Use Disorders Through System Change

OBJECTIVE

The Medication Research Partnership (MRP), a collaboration between a national commercial health plan and nine addiction treatment centers, implemented organizational and system changes to promote use of federally approved medications for treatment of alcohol and opioid use disorders.

METHOD

A difference-in-differences analysis examined change over time in the percentage of patients receiving a prescription medication for alcohol or opioid use disorders treated in MRP (n = 9) and comparison (n = 15) sites.

RESULTS

MRP clinics experienced a 2.4-fold increase in patients receiving an alcohol or opioid prescription (13.2% at baseline to 31.7% at 3 years after MRP initiation); comparison clinics experienced significantly less change (17.6% to 23.5%) with an adjusted difference-in-differences of 12.5% (95% CI [5.4, 19.6], p = .001). MRP sites increased the patients with prescriptions to treat opioid use disorder from 17.0% (baseline) to 36.8% (3 years after initiation), with smaller changes observed in comparison sites (23.2% to 24.0%) and a 3-year post-initiation adjusted difference-in-differences of 19% (95% CI [8.5, 29.5], p = .000). Medications for alcohol use disorders increased in both MRP (9.0% to 26.5%) and comparison sites (11.4% to 23.1%).

CONCLUSIONS

Promoting the use of medications to support recovery required complex interventions. The Advancing Recovery System Change Model, initially developed in publicly funded systems of care, was successfully adapted for commercial sector use. The model provides a framework for providers and commercial health plans to collaborate and increase patient access to medications.

The response of substance use disorder treatment providers to changes in macroeconomic conditions

OBJECTIVE

To study how substance use disorder (SUD) treatment providers respond to changes in economic conditions.

DATA SOURCES

2000-2012 National Survey of Substance Abuse Treatment Services (N-SSATS) which contains detailed information on specialty SUD facilities in the United States.

STUDY DESIGN

We use fixed-effects regression to study how changes in economic conditions, proxied by state unemployment rates, impact treatment setting, accepted payment forms, charity care, offered services, special programs, and use of pharmacotherapies by specialty SUD treatment providers.

DATA COLLECTION

Secondary data analysis in the N-SSATS.

PRINCIPAL FINDINGS

Our findings suggest a one percentage point increase in the state unemployment rate is associated with a 2.5% reduction in outpatient clients by non-profit providers and a 1.8% increase in the acceptance of private insurance as a form of payment overall. We find no evidence that inpatient treatment, the provision of charity care, offered services, or special programs are impacted by changes in the state unemployment rate. However, a one percentage point increase in the state unemployment rate leads to a 2.5% increase in the probability that a provider uses pharmacotherapies to treat addiction.

CONCLUSIONS

Deteriorating economic conditions may increase financial pressures on treatment providers, prompting them to seek new sources of revenue or to change their care delivery models.

Commercial Health Plan Coverage of Selected Treatments for Opioid Use Disorders from 2003 to 2014

Opioid use disorders (OUDs) are receiving significant attention in the U.S. as a public health crisis. Access to treatment for OUDs is essential and was expected to improve following implementation of the federal parity law and the Affordable Care Act. This study examines changes in coverage and management of treatments for OUDs (opioid treatment programs (OTPs) as a covered service benefit, buprenorphine as a pharmacy benefit) before, during, and after parity and ACA implementation. Data are from three rounds of a nationally representative survey conducted with commercial health plans regarding behavioral health services in benefit years 2003, 2010, and 2014. Data were weighted to be representative of health plans' commercial products in the continental United States (2003 weighted N = 7,469, 83% response rate; 2010 N = 8,431, 89% response rate; and 2014 N = 6,974, 80% response rate). Results showed treatment for OUDs was covered by nearly all health plan products in each year of the survey, but the types and patterns varied by year. Prior authorization requirements for OTPs have decreased over time. Despite the promise of expanded access to OUD treatment suggested by parity and the ACA, improved health plan coverage for treatment of OUDs, while essential, is not sufficient to address the opioid crisis.

Perceived Impacts of the Affordable Care Act: Perspectives of Buprenorphine Prescribers

The Affordable Care Act (ACA) has been heralded as a major policy change that is expected to transform the delivery of substance use disorder (SUD) treatment. Few studies have reported on the perceived impacts of ACA from the perspectives of SUD treatment providers, such as physicians who prescribe buprenorphine to patients with opioid use disorder. The present study describes buprenorphine prescribers' perceptions regarding impacts of the ACA on the delivery of buprenorphine and examines whether state-level approaches to implementing ACA are associated with its perceived impacts. Data are drawn from a national sample of current buprenorphine prescribers (n = 1,174) who were surveyed by mail. On average, buprenorphine prescribers reported ambivalence regarding the impacts of the ACA, as indicated by a mean of 2.75 (SD = 0.69) on a scale that ranged from 1 ("strongly disagree") to 5 ("strongly agree"). A multi-level mixed-effects regression model indicated that physicians practicing in states that were supportive of ACA, as indicated by adopting both the Medicaid expansion and implementing a state-based health insurance exchange, had more positive perceptions of the ACA than physicians in states that had declined both of these policies. This study suggests that state approaches to ACA may be associated with varied impacts.