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

Abstract

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We conducted case studies in five U.S. states, interviewing key informants and reviewing the published literature and unpublished documents.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

Preventing and treating prescription and illicit opioid misuse and dependence has become one of the highest policy priorities in the United States over the past decade in response to substantial increases in the rates of opioid-related overdose deaths (Centers for Disease Control and Prevention, 2011, 2017; National Center for Health Statistics, 2019) and high rates of opioid misuse and opioid use disorder (McCance-Katz, 2018; Substance Abuse and Mental Health Services Administration, 2018). One challenge in addressing the opioid epidemic is the underutilization of medications that are effective in treating opioid use disorder: methadone, naltrexone, and buprenorphine (National Institute on Drug Abuse, 2017). Widespread use of medication-assisted treatment (MAT) has been constrained by limited provider capacity and willingness to prescribe MAT (Andrilla et al., 2018; Bouchery et al., 2015; Jones & McCance-Katz, 2019; Jones et al., 2015), financing (Mark et al., 2016), and resistance from individuals to seek treatment (Jones & McCance-Katz, 2019).

Several policies have been enacted recently to expand insurance coverage and financing of MAT, such as the Mental Health Parity and Addiction Equity Act of 2008, the Patient Protection and Affordable Care Act of 2010, the 21st Century Cures Act of 2016, and the SUPPORT for Patients and Communities Act of 2018. The federal government has appropriated upward of $1 billion in funding to address the opioid epidemic in the past 2 years, but that amount only represents less than a 3% increase in the annual $34 billion in substance use disorder (SUD) expenditures (U.S. Department of Health and Human Services, 2018). Despite significant federal, state, and local attention on the opioid epidemic over the past 5 years, the opioid epidemic has not slowed down (Substance Abuse and Mental Health Services Administration, 2018).

Comprehensive approaches to system-wide change to address the opioid epidemic may take time to implement and require significant action at the state and local level. It is important to recognize that, although increased federal funding and guidance are crucial catalysts for states to increase MAT access, states also have other levers to address access. In this study, we describe innovative approaches from five states to increase MAT financing and access and examine the associated literature on the effects of these policy levers.

Method

We conducted case studies in five states: California, Missouri, New Hampshire, Ohio, and Virginia (for more details on the methods, see Hinde et al., 2018). For each state, we conducted an in-depth review of state policies. We also had discussions with 15 stakeholders, three in each state. Stakeholders included state-level officials, such as state Medicaid or Single State Agency staff; local officials, such as regional or county behavioral health agency directors; and other state payer or provider organizations. Discussions were facilitated using a semistructured guide that focused on existing MAT treatment systems as well as the challenges stakeholders identified concerning MAT infrastructure, financing, and workforce within their state. Qualitative and descriptive analysis of the discussions across states yielded several common themes to facilitate expansion of MAT treatment and recovery support services.

Results

The case studies highlighted five key policy levers that states used to increase MAT access and financing: Medicaid expansion, Medicaid Section 1115 demonstrations, federal grant funding, contracting arrangements, and regulation changes. We discuss each below.

Medicaid expansion

Three of the five states had expanded Medicaid at the time of our research (California, New Hampshire, Ohio). All three reported that the Patient Protection and Affordable Care Act’s Medicaid expansion was the most significant lever that states had to expand financing and access to MAT. Medicaid expansion provided insurance coverage to individuals and families earning at or below 138% of the federal poverty level. In California, it was expected that 10%–12% of the newly eligible population had an SUD (Substance Abuse and Mental Health Services Administration, 2013; Teare, 2017). Ohio and New Hampshire reported higher than expected SUD rates among newly Medicaid-eligible individuals, 33% and 16%, respectively (New Hampshire Department of Health and Human Services, 2016; Ohio Department of Medicaid, n.d.). Ohio reported a sharp increase in demand for MAT from newly enrolled individuals and that new and existing providers were more willing or able to accept patients for MAT after Medicaid expansion, and that state funding that previously went to covering the uninsured could be shifted for prevention and other services not covered under Medicaid.

New Hampshire’s Medicaid program offered almost no SUD benefits before Medicaid expansion and used Medicaid expansion to enhance SUD services under the medical component of MAT, such as peer recovery services, intensive outpatient treatment detoxification services, and counseling. The enhanced federal match incentivized New Hampshire to include a more generous set of benefits and reimbursement rates than required by law. New Hampshire stakeholders also reported that Medicaid expansion freed up state revenues for infrastructure and workforce development to increase MAT capacity in medical settings.

Findings from our states have been corroborated in the literature with decreases in the uninsured rate among individuals with SUD (Mark, 2019), increases in Medicaid-covered buprenorphine prescriptions and spending (Saloner et al., 2018; Wen et al., 2017), and increases in new MAT providers and Medicaid acceptance among existing MAT providers (Meinhofer & Witman, 2018).

Medicaid Section 1115 SUD demonstrations

Beginning in 2015, the Centers for Medicare and Medicaid Services offered states the opportunity to pursue Medicaid demonstration projects authorized under Section 1115 to pilot comprehensive Medicaid coverage of SUD treatment services and MAT in the context of overall SUD service delivery transformation and to receive Medicaid federal matching funds for services provided in residential treatment programs with more than 16 beds (referred to as the institutions for mental disease restriction; Centers for Medicare and Medicaid Services, 2015). At the time of our study, two states in the study—California and Virginia—were implementing 1115 SUD demonstrations.

Virginia began implementing its Medicaid SUD demonstration in April 2017 and added inpatient and residential detoxification and SUD treatment and peer support services. The demonstration also increased Medicaid reimbursement rates for SUD treatment with co-located MAT and behavioral health providers, which quickly increased the number of co-located MAT and behavioral health providers from 0 to 28. During the first 5 months of the demonstration, there was a 25% increase in the number of Medicaid members receiving buprenorphine pharmacotherapy (Walker et al., 2018). Nearly half (48%) of buprenorphine users also received at least one other opioid use disorder outpatient, residential, or inpatient treatment service, and the number of residential treatment centers accepting Medicaid increased from 4 to 71 facilities.

Before the demonstration, Medicaid SUD treatment in California was managed by individual counties under a program separate from the rest of Medicaid, Drug Medi-Cal, with a limited set of SUD treatment services. California used the demonstration to add coverage of buprenorphine in specialty SUD programs and coverage of comprehensive intake assessments, counseling, medication management, physician consultation, and peer navigators in SUD specialty programs. Buprenorphine was covered under the Medicaid medical benefit before the demonstration but was not reimbursable in methadone maintenance clinics or other specialty SUD programs. A 2017–2018 evaluation did not find evidence that the demonstration was increasing the provision of MAT to patients treated in specialty SUD programs. However, it may be that most MAT is being provided under the medical Medicaid program and not reported in county SUD agencies’ administrative data (Urada et al., 2018).

Federal grant funding

States reported using their State Targeted Response to the Opioid Crisis (STR) and State Opioid Response (SOR) grant funding primarily to expand capacity in medical settings, provide start-up costs for pilot programs, finance MAT and related services for the uninsured, and train providers. Ohio is implementing MAT induction programs into emergency departments to provide interim care until an office-based opioid agonist treatment or an opioid treatment program spot becomes available. In the emergency department model, medical providers receive training in both screening, brief intervention, and referral to treatment (SBIRT) and American Society of Addiction Medicine concepts, and grant-funded case managers support medical providers to develop a care plan at discharge. Clients are linked to telehealth or inperson counseling services, office-based opioid agonist treatments, opioid treatment programs, or detoxification centers to promote a continuum of care.

Missouri leveraged several grant programs to increase MAT access capacity in both SUD and non-SUD treatment settings. Through STR/SOR grant funding, Missouri is using multidisciplinary implementation teams, comprising a physician, nurse, addiction counselor, peer support worker, and a billing administrator to build capacity in emergency departments and primary care clinics. The teams train providers on MAT and train administrative and support staff on how to coordinate across medical and behavioral health systems and bill for MAT. Rather than fund services in the short term, stakeholders felt the implementation teams could better coordinate and use existing resources in a sustainable way. Missouri also has worked with federally qualified health centers to obtain Health Resources & Services Administration funding to provide MAT and used a Substance Abuse and Mental Health Services Administration MAT-Prescription Drug and Opioid Addiction grant to increase MAT capacity in integrated care settings in high-risk regions in the state.

California used STR/SOR funding to implement a Hub-and-Spoke system, certifying 19 Hubs to cover 32 counties. Under the Hub-and-Spoke model, hubs provide intensive opioid use disorder treatment for individuals in need of intensive or complex care, while the spokes are typically primary care practices that can prescribe MAT and offer counseling for less complex patients (State of Vermont, 2019). Virginia also used STR/SOR funds to provide 90 days of MAT and SUD treatment services to uninsured individuals in high-risk regions in the state, tripling the amount of treatment available. California, Missouri, and Ohio also were using STR/SOR funding to provide and incentivize buprenorphine waiver training.

Leveraging contracts

States increased and incentivized expansion of MAT by leveraging contracts with their providers. Missouri established volume purchase contracts for extended-release injectable naltrexone and for drug tests of state-funded and Medicaid beneficiaries. Missouri also required its contracted providers to offer all forms of MAT to be able to bill the state substance abuse agency for any SUD services. In establishing this requirement, state officials and providers discovered that reimbursement rates did not adequately cover the administration and overhead costs related to MAT. As a result, the state substance abuse agency raised the reimbursement rates.

Another creative contracting arrangement in Missouri was a “middle-man” setup that connected funding to office-based opioid agonist treatments through a regional behavioral health organization. Office-based opioid agonist treatments are not generally licensed by the Single State Agency and cannot directly receive Single State Agency funding. Instead, the licensed behavioral health organization sets subcontracts with independent MAT providers, the MAT providers bill the organization for MAT, and the organization bills the state. The MAT providers receive guaranteed payment at predetermined rates and do not have to deal with the state or insurance companies. Providers appreciate this arrangement, and the behavioral health organization quickly expanded their prescribing network.

Regulations

Virginia and Missouri reduced prior authorization for MAT to enhance access. Virginia removed prior authorization requirements for buprenorphine entirely for office-based providers who meet certain requirements and had a co-located behavioral health provider (referred to as a “Gold card”). Missouri modified their buprenorphine prior authorization process that could take 4 to 6 hours per patient. In Missouri, a patient originally had to have a complete assessment and diagnosis, then be admitted to a Medicaid- or state-funded SUD program, and then obtain a referral to MAT. Missouri changed its prior authorization policies for buprenorphine and buprenorphine/naloxone to require only a diagnosis of opioid drug dependence in the last 2 years; a current assessment can then occur within a 30-day grace period. Another policy change allowed medical providers to complete the MAT screening and eligibility protocol, instead of first needing a behavioral health provider to file a referral.

Ohio addressed a different type of regulatory barrier for opioid treatment programs. While maintaining the federal regulations regarding opioid treatment program certification and monitoring, Ohio passed legislation that allowed for-profit methadone clinics to open and waived the statutory requirement that community SUD services providers must be certified for at least 2 years before opioid treatment program licensure (Medicaid and CHIP Payment and Access Commission, 2017; Ohio Legislative Service Commission, 2016) and started allowing opioid treatment programs to bill for buprenorphine (Ohio Department of Health, 2017).

Conclusion

Federal, state, and local policymakers recognize the importance of expanding MAT capacity and financing in reducing the impact of the opioid epidemic. This study identified approaches that five states are using to achieve this goal. States reported that Medicaid expansion was the most important lever for increasing MAT access because it granted insurance eligibility for many individuals with opioid use disorder and allowed states to redirect funds to cover MAT for the remaining uninsured and invest in infrastructure.

Medicaid 1115 SUD demonstrations are another potentially viable mechanism to increase MAT access through system-wide changes in SUD coverage and delivery, although robust evidence of their impacts is not yet established (U.S. Government Accountability Office, 2018). Medicaid Section 1115 demonstrations provide opportunities to tailor system-wide change. The Centers for Medicare and Medicaid Services has recently taken steps to increase the rigor of 1115 evaluations, which may improve our understanding of these types of system-wide changes.

This study echoes other calls (Underhill et al., 2018) for more funding of rigorous research and evaluation of MAT and SUD policies. More research is needed to understand how Medicaid policy changes have affected MAT access and, more importantly, substance use and related outcomes. Broadly speaking, alternative delivery and payment models, contracting mechanisms, and other regulations are under-studied policy levers for SUD services like MAT. Not nearly enough empirical studies are being conducted that demonstrate the extent to which these state and local policies are effective in increasing access to MAT. States in this study report substantial progress in increasing access to MAT, and more research is needed to document the context and drivers of increased access to MAT for replication and dissemination.