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. Author manuscript; available in PMC: 2024 Jun 1.
Published in final edited form as: J Subst Use Addict Treat. 2023 Apr 12;149:209034. doi: 10.1016/j.josat.2023.209034

Use of residential opioid use disorder treatment among Medicaid enrollees in nine states

Lindsay Allen a,*; Medicaid Outcomes Distributed Research Network (MODRN), Evan Cole b, Michael Sharbaugh b, Anna Austin c, Marguerite Burns l, Chung-Chou Ho Chang m, Sarah Clark e, Dushka Crane f, Peter Cunningham d, Christine Durrance k, Carrie Fry g, Adam Gordon h, Lindsey Hammerslag i, Joo Yeon Kim n, Susan Kennedy j, Sunita Krishnan j, Rachel Mauk f, Jeff Talbert i, Lu Tang o, Julie M Donohue b
PMCID: PMC10719813  NIHMSID: NIHMS1948487  PMID: 37059269

Abstract

Introduction:

Residential treatment is a key component of the opioid use disorder care continuum, but research has not measured well the differences in its use across states at the enrollee level.

Methods:

This cross-sectional observational study used Medicaid claims data from nine states to document the prevalence of residential treatment for opioid use disorder and to describe the characteristics of patients receiving care. For each patient characteristic, chi-square and t-tests tested for differences in the distribution between individuals who did and did not receive residential care.

Results:

Among 491,071 Medicaid enrollees with opioid use disorder, 7.5 % were treated in residential facilities in 2019, though this number ranged widely (0.3–14.6 %) across states. Residential patients were more likely to be younger, non-Hispanic White, male, and living in an urban area. Although residential patients were less likely than those without residential care to be eligible for Medicaid through disability, diagnoses for comorbid conditions were more frequently observed among residential patients.

Conclusions:

Results from this large, multi-state study add context to the ongoing national conversation around opioid use disorder treatment and policy, providing a baseline for future work.

Keywords: Medicaid, Opioid use disorder, Residential treatment

1. Introduction

The opioid epidemic continues to devastate the United States, with 1.6 million people diagnosed with opioid use disorder (OUD) in 2019 (Substance Abuse and Mental Health Services Administration, 2020). Combating this public health emergency requires transitioning individuals with OUD into meaningful long-term recovery, yet over half of those needing treatment do not receive care (Mauro et al., 2022).

Residential treatment is a critical component of the substance use care continuum (American Society of Addiction Medicine, 2020), though the evidence for its effectiveness for OUD remains mixed (de Andrade et al., 2019). Residential facilities provide structured, 24-h care focused on intensive recovery activities and account for more than one-quarter of national substance use treatment spending (Beetham et al., 2021; Reif et al., 2014).

Within Medicaid, which covers a disproportionate share of individuals with OUD, financing for residential treatment is of central policy importance (Orgera & Tolbert, 2019). Historically, federal law prohibited Medicaid payments for residential treatment to preserve state financing of these services (Orgera & Tolbert, 2019). In 2015, however, the Centers for Medicare and Medicaid Services began to offer mechanisms (e.g. Section 1115 waivers, the SUPPORT Act) through which individual states could request funding for residential OUD treatment (Guth et al., 2020; Musumeci & Tolbert, 2018; Orgera & Tolbert, 2019; Paradise & Musumeci, 2016; Wachino, 2015).

As more Medicaid agencies begin covering residential OUD treatment, research must capture use of residential OUD treatment across state Medicaid populations, for benchmarking purposes and to help guide policy decisions. However, making lateral comparisons of treatment use across states has been difficult because state Medicaid programs define and reimburse for residential treatment differently. To overcome this challenge, the current study leverages the Medicaid Outcomes Distributed Research Network (MODRN) Common Data Model (CDM) to compare residential treatment use across nine states. The study aims were to document the percentage of enrollees who were treated in residential facilities, across states and overall, as well as document differences in the characteristics of those who did and did not receive residential treatment.

2. Methods

Since its 2017 inception, MODRN has developed a CDM containing standardized sets of Medicaid administrative claims data from 13 states; this study uses the nine datasets (from Delaware, Kentucky, Maryland, Michigan, North Carolina, Ohio, Pennsylvania, Virginia, West Virginia) that included residential claims and were completed by the start of the analysis (Zivin et al., 2022). Each of the nine states applied identical statistical software code—distributed by a data coordinating center—to its state’s Medicaid data, which had been transformed into a uniform CDM structure and set of data elements. This approach allowed for lateral comparisons of Medicaid data analyses across states. The nine states that took part in this study represent 14.9 million individuals, amounting to 20.0 % of all US Medicaid enrollees. Results from each state were de-identified due to confidentiality agreements with the state partners.

The study cohort included enrollees ages 12–64 with at least 6 months of continuous full-benefit enrollment in 2018 and another 6 months of continuous full-benefit enrollment in 2019. Individuals had to have a diagnosis of OUD on at least one claim in either 2018 or 2019 to be included in the study. The primary outcome was whether an enrollee had at least one residential treatment episode during 2019. The study included all episodes with an OUD diagnosis on ≥1 claim that lasted for >1 day.

Enrollee characteristics [age (12–34 vs. 35–64); sex (male vs. female); race/ethnicity (non-Hispanic White versus all others; more granular race/ethnicity groups were not used due to small cell sizes in some states); urbanicity (nonurban vs. urban); eligibility group (disability vs. other); and the presence of other mental health (anxiety, mood, psychotic) and/or other substance use disorder] were summarized among enrollees with a residential treatment episode and those without, combined across states and individually by state. Using aggregated data from each state, the data coordinating center conducted chi-square and t-test analyses to examine differences between enrollees with or without a residential treatment episode, within each state or combined across states, using SAS (9.4) and R (4.0.4).

3. Results

The final analytic sample comprised 491,071 Medicaid enrollees with OUD across nine states. Fig. 1 documents that across all states combined, 7.5 % of enrollees with OUD engaged in residential treatment. Among the individual states, this percentage ranged widely, from 0.3 % (in State D) to 14.6 % (in State F).

Fig. 1.

Fig. 1.

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Percentage of Medicaid enrollees diagnosed with opioid use disorder who had at least one residential treatment episode, by state, 2019.

Source: Authors’ analysis of Medicaid administrative claims data

Notes: Table reflects a total of 491,071 enrollees. State labels skip from State G to State I, to conform to the key used in other MODRN publications.

Table 1 displays the characteristics of enrollees with OUD who did or did not receive residential treatment in 2019, overall and within each state. Overall, those who received residential care were more likely to be under 35 years old compared to those who did not receive residential care (55.2 vs. 40.7 %, p < 0.001). Within individuals who received residential care, the percentage under 35 varied by state, from 46.1 % (State B) to 66.7 % (State I). In general, the proportion of enrollees who were male was higher for the residential treatment group (57.5 vs. 44.7 %, p < 0.001). Although the overall majority of people in residential treatment were male, in three states male individuals instead composed a smaller segment of the population receiving residential care. Females represented the majority of individuals not receiving residential care in all but one state (State B). Overall, about three quarters of enrollees with OUD who did and did not receive residential care were non-Hispanic white, though slightly fewer individuals were non-Hispanic white in the residential treatment group (74.1 vs. 74.6 %, p < 0.05). In five of nine states, the study found no statistical difference in the percentages of non-Hispanic White enrollees among those receiving residential treatment versus not.

Table 1.

Characteristics of enrollees diagnosed with opioid use disorder who did and did not enter residential treatment, by state, 2019.

Patient characteristic Residential treatment All State
A B C D E F G I J
Under 35 (%) Yes 55.2*** 58.7*** 46.1*** 52.4*** 64.3*** 60.6*** 54.8*** 52.8*** 66.7*** 53.4***
No 40.7 40.1 37.0 36.7 43.9 42.8 40.5 41.1 50.5 38.0
Male sex (%) Yes 57.5*** 53.0*** 64.0*** 56.8*** 34.5 54.2*** 59.7*** 28.9 47.9* 63.7***
No 44.7 45.4 52.9 46.0 30.1 44.3 46.2 27.8 44.3 46.2
Non-Hispanic White (%) Yes 74.1* 86.2 50.6*** 72.4 52.4** 82.8*** 74.2 78.1 86.0** 66.1
No 74.6 85.4 55.7 72.4 69.1 79.5 74.0 77.2 89.4 63.5
Disability Eligible (%) Yes 11.1*** 7.2*** 13.6*** 16.1*** 28.6   7.8*** 12.2*** 26.9***   0.1   4.7***
No 20.1 16.4 19.1 23.4 35.3 16.4 24.1 38.3   0.3 14.6
Anxiety Disorder (%) Yes 72.9*** 78.5*** 61.3*** 76.4*** 69.0 79.7*** 71.1*** 75.6*** 76.6*** 72.1
No 60.0 60.4 48.6 66.3 61.0 64.9 57.4 64.1 53.9 67.7
Mood Disorder (%) Yes 76.2*** 76.8*** 77.1*** 79.3*** 66.7 78.0*** 74.0*** 79.4*** 78.3*** 75.5***
No 59.7 55.0 58.0 64.6 61.3 63.2 58.1 64.3 54.2 58.3
Psychotic Disorder (%) Yes 19.0*** 19.1*** 15.8*** 25.4*** 15.5 21.5*** 17.8*** 26.6*** 14.8*** 13.9**
No 11.1   8.2 10.5 13.7 12.4 12.7 11.0 14.0   6.8   9.2
Co-occurring SUD (%) Yes 90.9*** 95.7*** 84.4*** 89.5*** 84.5*** 95.7*** 89.9*** 84.9*** 93.0*** 87.1***
No 57.4 56.9 53.0 58.0 55.2 67.7 52.4 49.6 56.3 51.2
Resided in Non-urban Area (%) Yes 18.6*** 50.7***   4.2 11.7*** 35.7 26.0   9.6*** 26.6 26.6*   6.3***
No 26.8 62.9   4.3 20.4 31.9 27.1 14.6 29.2 30.1 15.6
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Source: Authors’ analysis of Medicaid administrative claims data.

Notes: Table reflects a total of 491,071 enrollees, 36,641 (7.5 %) of whom received residential treatment. Percentages are row percentages. Stars represent statistically significant differences between the population who received versus did not receive residential care, within each state or overall, at *** p < 0.001 **p < 0.01 *p < 0.05 levels. State labels skip from State G to State I, to conform to the key used in other MODRN publications. SUD=substance use disorder

Those eligible for Medicaid via disability composed 11.1 % of those receiving residential care, and 20.1 % of those not receiving care (p < 0.001). This pattern was consistent across each individual state. Diagnoses for co-occurring behavioral health conditions were significantly more frequent among those who received residential treatment vs. those who did not, especially anxiety (72.9 vs. 60.0 %, p < 0.001), mood (76.2 vs. 59.7 % p < 0.001), and additional co-occurring substance use disorders (90.9 vs. 57.4 %, p < 0.001). This pattern was consistent across states.

Those living in nonurban areas composed 18.6 % of enrollees receiving residential care, and 26.8 % of those not receiving care (p < 0.001). Among those receiving residential care, the rate of residents living in nonurban areas varied across states, from 4.2 (State B) to 50.7 % (State A). In four states, however, the rate of nonurban enrollees was not statistically different across those receiving versus not receiving residential care.

4. Discussion

This study is the first to compare the prevalence of residential OUD treatment across multiple states’ Medicaid populations. A key takeaway is that the prevalence of residential care varies widely across states, which reflects the substantial flexibility state Medicaid programs have in designing OUD treatment policy (Cole et al., 2021). At the federal level, Medicaid prohibits reimbursement for residential facilities with >16 beds, but some states have obtained Section 1115 waivers or use other mechanisms to reimburse for residential care (O’Brien et al., 2019). Even when health plans cover residential OUD treatment, policies across states may vary. For example, states may subject reimbursement to varied utilization management limits, such as providing services only in 7-day increments or with a total average length of stay of 30 days (O’Brien et al., 2019).

Variation in treatment rates may also be due to differences in residential treatment supply. Given that <70 % of facilities accept Medicaid, supply shortages might be particularly acute for the Medicaid enrollees (SAMHSA, 2020). Improving supply will require policy solutions and resources from within the Medicaid program, such as increasing payment rates, as well as from outside, such as loan forgiveness programs drawing providers to underserved areas. For the substantial number of facilities that do not accept any insurance, offering insurance flexibilities and billing assistance (i.e., demonstrating the value of insurance) are potential mechanisms for incorporating them into the health insurance infrastructure.

Mixed evidence on the efficacy of residential treatment might also affect usage rates. Though moderate quality evidence exists of residential treatment’s effectiveness, this body of literature suffers from methodological flaws (particularly attrition), making it difficult to describe best practice approaches to residential treatment delivery (de Andrade et al., 2019). Though many factors might affect residential treatment efficacy, a particularly well-studied one is the use of MOUD during the stay. Though research has shown MOUD to increase short-term residential retention and completion, only a small share of admissions had MOUD in a treatment plan (Huhn et al., 2020; Stahler & Mennis, 2020). Barriers to offering MOUD in residential facilities may include legal and regulatory barriers associated with buprenorphine or methadone prescribing, variability in insurance reimbursement, and/or integration between paraprofessionals and clinicians (Huhn et al., 2020); policies aimed at improving each of these targets might improve the quality of residential care.

This study also documented the characteristics of Medicaid enrollees who received residential treatment for OUD. Those receiving residential treatment were more likely to be younger, non-Hispanic White, male, and living in an urban area. Though these results parallel the characteristics of those historically most likely to experience opioid overdose, attention must be paid to rising rates of OUD among groups less likely to receive residential care. For example, overdose rates have rapidly grown among older adults, with the rate of those seeking treatment for heroin use rising 110 % between 2012 and 2015. Notably, this population is increasingly female and African American (Salmond & Allread, 2019).

This study has limitations. First, all states in the analysis are in the eastern part of the United States, and the results may not generalize to other areas, where treatment norms or other factors may differ. Second, this cross-sectional study represents a snapshot at a single time point and cannot support conclusions on causal relationships between any of the described patient characteristics and outcomes. Some of the variation in characteristics of residential patients may parallel the demographics of each state’s unique OUD patient population. Therefore, results from this study should not be taken as evidence for disparities in access to treatment. Future work should aim to identify whether, and for whom, such disparities exist. As a complement to that line of work, evidence about residential treatment’s effectiveness, key components of care, and relative role in the care continuum is needed to inform the broader residential treatment research agenda. Additional work should replicate this study in other payer populations, such as the commercially insured or Medicare enrollees, as our results may not generalize to those groups.

In sum, this study documented heterogeneity in the prevalence of residential treatment for OUD among Medicaid enrollees in nine states. Results from this study may be used as a baseline for tracking the impact of Medicaid policies aiming to improve access to residential treatment, such as the many 1115 substance use disorder waiver demonstration projects currently being evaluated. Further, these findings serve as an important starting point for data-driven policy discussions aimed at alleviating the US opioid crisis.

Funding

All authors received generous support from the National Institute on Drug Abuse [5R01DA048029] for this work. The authors have no competing interests to declare.

Footnotes

Declaration of competing interest

The authors have no competing interests to declare.

CRediT authorship contribution statement
Lindsay Allen Conceptualization, methodology, project administration, writing – original
Evan Cole Conceptualization, methodology, project administration, writing – revising
Michael Sharbaugh Conceptualization, data curation, methodology, formal analysis
Anna Austin Conceptualization, writing – revising
Marguerite Burns Conceptualization, investigation, writing – revising
Chung-Chou Ho Chang Conceptualization, methodology
Sarah Clark Conceptualization, writing – revising
Dushka Crane Conceptualization
Peter Cunningham Conceptualization
Christine Durrance Conceptualization, writing – revising
Carrie Fry Conceptualization
Adam Gordon Conceptualization
Lindsey Hammerslag Conceptualization, writing – revising
Joo Yeon Kim Conceptualization
Susan Kennedy Conceptualization
Sunita Krishnan Conceptualization
Rachel Mauk Conceptualization, data curation, software, formal analysis, writing - revising
Jeff Talbert Conceptualization
Lu Tang Conceptualization, methodology
Julie Donohue Conceptualization, supervision, funding acquisition
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Appendix A. Supplementary data

Supplementary data to this article can be found online at https://doi.org/10.1016/j.josat.2023.209034.

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