MM Curator summary

The article below has been highlighted and summarized by our research team. It is provided here for member convenience as part of our Curator service.

[MM Curator Summary]: Medicaid members need help with this.

Clipped from: https://www.kff.org/medicaid/issue-brief/a-look-at-substance-use-disorders-sud-among-medicaid-enrollees/

Deaths due to substance use disorder (SUD) have risen sharply during the pandemic, highlighting longstanding gaps—such as under-identification and undertreatment of SUD. Even before the pandemic, SUD contributed to a large and growing share of deaths. For example, alcohol was listed as a contributing factor in 20% of deaths in adults between the ages of 20 and 49 from 2015 to 2019 and drug overdose deaths increased by 35% over the same period. Yet in 2019, only 1 in 10 people (12 and older) with past year SUD received any treatment, including specialty treatment or self-help groups. The Medicaid population may be particularly impacted, as 21% have mild, moderate, or severe SUD, compared to 16% of commercially insured. In its role as a public program and the single largest payer of behavioral health services in the country, Medicaid is particularly positioned to implement policy to improve the delivery, quality, and effectiveness of behavioral health services. The detailed and comprehensive claims data available for Medicaid can help answer questions and inform policy.

Efforts are being made at the state and federal levels to increase SUD awareness, coordination, and treatment access—including some provisions that were recently passed as a part of the Consolidated Appropriations Act enacted in December 2022, such as expanding providers who are able to prescribe buprenorphine for treating OUD. In light of recent efforts to expand access to SUD treatment services, we examine the share of enrollees with SUD using both Medicaid claims and data from the National Survey on Drug Use and Health (NSDUH).

What are the rates and characteristics of Medicaid enrollees with identified SUD?

In 2019, 7.3% of Medicaid enrollees ages 12 to 64 had at least one clinically-identified SUD in Medicaid claims data. Opioid use disorder was identified in 3.3% of Medicaid enrollees; alcohol use disorder in 2.5%; cannabis use disorder in 1.9%; stimulant use disorder (including cocaine or other stimulants) in 1.7%; and 1.7% of Medicaid enrollees had some other type of substance use disorder. These groups were not mutually exclusive, and while we did not look at the share of people with multiple substance use disorders, it is not uncommon for substance use disorders to co-occur. For this analysis, any diagnosis or prescription code that suggests the presence of a SUD is flagged as a “clinically-identified SUD.” This is not a measure of overall prevalence of SUD because not everyone is screened and diagnoses are not always recorded, but it does provide some insight into how often SUD is recognized and possibly treated in clinical settings (Figure 1).

People with clinically-identified SUD are more likely to be male, White, over 25 years old, and qualify for Medicaid based on a disability or through Medicaid expansion. At least one clinically-identified substance use disorder is found in Medicaid claims data for 8.9% of males, 10.0% of White people, and 11.6% of individuals aged 35 to 49. Medicaid beneficiaries who qualify as a result of a disability or through Medicaid expansion have higher rates of clinically-identified SUD than other groups. This pattern holds across most types of SUD, with only a few exceptions. For example, alcohol use disorder is most commonly identified among people aged 50 to 64, while cannabis use disorder is the most commonly identified among people aged 26 to 34. Clinically-identified SUD rates are highest among White people for all substance types except cannabis, where Black people have similar or slightly higher rates (2.4% versus 2.1%, respectively) (Figure 2).

Rates of clinically-identified SUD vary widely by state. Vermont has the highest share of any clinically-identified SUD, with 13.3% of Medicaid enrollees having a clinically-identified SUD, while Arkansas has the lowest rate, with only 3% of Medicaid enrollees having at least one clinically-identified SUD (Figure 3). Rates of clinically-identified SUD vary across states not only because of prevalence, but also because of other factors, such as provider screening behavior and variation in Medicaid coverage of SUD services.

What are implications of findings from claims data?

Other data sources generally suggest that SUD rates from Medicaid claims are undercounts—but even national survey data may undercount SUD for a variety of reasons. National prevalence of SUD is estimated through surveys such as the National Survey of Substance Use and Health (NSDUH), which uses questions based on diagnostic criteria to identify individuals with SUD, including those who haven’t already been diagnosed. We analyzed NSDUH data and found that the prevalence estimates of SUD among Medicaid enrollees is generally higher in national survey data than in Medicaid claims data, and that difference is greatest among adolescents, young adults, and Hispanic people. Even national survey data may undercount SUD due to underreporting of substance use and exclusion of unhoused, incarcerated, and institutionalized people—which are populations where SUD may be more prevalent. Research that adjusts for these undercounts estimates that alcohol and opioid use disorders are at least four times more prevalent than the NSDUH estimates.

National recommendations instruct providers to screen for substance use and conduct brief interventions for adults 18+, yet there may be gaps between SUD screening and referral. Research found that while most patients with an alcohol use disorder were screened for alcohol use, only 14.6% received brief interventions from their providers, and even fewer–about 6%–were referred to treatment.  Despite the serious
health consequences and comorbidity of physical health and SUD conditions, most doctors do not receive much training in substance use disorders. Even within psychiatric residency programs, only 2% of training time is dedicated to substance use disorders. According to fourth-year medical students in Massachusetts, fewer than one-fifth report feeling very prepared to screen for opioid use disorders and/or refer patients with related symptoms to treatment.

Other factors–such as patient privacy concerns or few healthcare visits–may also play a role in low identification of SUD. Even when providers ask about substance use, patients may feel uncomfortable disclosing their use or may be worried about stigma or legal consequences if they do. Even if a SUD is identified, providers may be hesitant to record it due to concerns about whether recording the SUD violates the privacy rules that add additional protections for people receiving SUD treatment. Other reasons may be population specific. For example, people who are younger and generally healthier may have fewer health care appointments and therefore fewer opportunities for providers to identify SUD. In at least one state, school-based screenings are required for younger populations. Growing drug overdose deaths among adolescents and people of color may suggest disparities in the identification and treatment of SUD.

There is broad variation in Medicaid policy and coverage of SUD services across states. Medicaid coverage of SUD services, as well as utilization management policies, such as prior authorization, can vary widely across states (and even across managed care organizations within states). Although more comprehensive coverage of SUD services has been linked to higher Medicaid acceptance by SUD treatment facilities, as of 2018, only 12 states covered the full continuum of SUD services. People experiencing symptoms of a substance use disorder may find it difficult to navigate this complex landscape, and difficulty accessing treatment is likely exacerbated in areas with workforce shortages.

Looking Ahead

In response to the growing number of overdose deaths and longstanding challenges accessing SUD treatment, state and federal governments have taken action to address ongoing gaps in SUD care—from identification of SUD to treatment. For example, many Medicaid programs have expanded coverage of SUD services and extended benefits to new eligibility groups; increased provider reimbursement rates for SUD services; and/or permanently adopted or continued pandemic-era telehealth expansions for behavioral health services.

At a federal level, HHS has issued notices of proposed rulemaking that may result in improved coordination of SUD services (42 CFR part 2) and expanded access to methadone for opioid use disorder treatment. Congress passed the Consolidated Appropriations Act (CAA) in December 2022, with funding to improve SUD awareness, prevention, treatment, coverage, and increase workforce. For example, the CAA added at least 100 new residency positions dedicated to psychiatry and required that all prescribers of controlled substances undergo training in managing and treating patients with SUD. CAA also lifted some administrative barriers to expand access to medications to treat opioid use disorder including the removal of additional registration requirements for prescribing buprenorphine (X-waiver) and reduced barriers to opioid treatment programs. Recent legislative efforts may lessen some longstanding barriers to SUD care, which could lead to better identification, referral, and treatment of SUD.

Methods

Medicaid Claims (T-MSIS) and State Exclusion Criteria

This analysis uses the following 2019 T-MSIS Research Identifiable claims files: demographic eligibility base (DE) and header and line files from inpatient (IP), long-term care (LT), other services (OT), and prescription (RX) claim files.

We use 48 states and D.C. in the main analysis and 29 states in our analyses that include race and ethnicity. We evaluated states’ claims data using the DQ Atlas criteria and by comparing SUD estimates from T-MSIS to NSDUH. Specific DQ Atlas measures used to determine state data quality include the restricted benefits code, Medicare benefits code, OT claims/encounter volume. We excluded Alabama because the Medicare coverage code was missing for more than 10% of enrollees and the T-MSIS SUD rates were 93 percent lower than NSDUH estimates. We excluded Colorado because the OT file encounter data volume was below 50% of the national median and the T-MSIS SUD rates were 156 percent lower than NSDUH estimates. For analyses involving race/ethnicity, the following states rated as “high concern” or “unusable” data by the DQ Atlas were also excluded:  AL, AZ, AR, CO, CT, DC, HI, IA, KS, LA, MD, MA, MO, MT, NY, OR, RI, SC, TN, UT, WV, WY.

T-MSIS Enrollee Sample Selection

Our sample includes nonelderly Medicaid and CHIP enrollees between the ages of 12 and 64 that have at least one day of enrollment in 2019. Enrollees were excluded if they did not have full or comprehensive Medicaid, had Medicare coverage, or were enrolled for less than one month in 2019. These exclusions are similar to those reported in the CMS SUD data book
technical specifications, but the CMS data book included people with Medicare coverage. After enrollee and data quality exclusions, our main sample includes 46,967,389 enrollees from 48 states and the District of Columbia.

Identification of SUD in T-MSIS

We linked header and line files using MSIS_ID and CLM_ID and linked claims files to the DE file using MSIS_ID (see the T-MSIS User Guide for information on linking variables) for fee-for-service and encounter claims. We identified ICD-9 and ICD-10 diagnosis codes and National Drug Codes (NDCs) from an adapted version of reference codes used in the 2019 CMS SUD data book. Modifications to CMS SUD reference codes include (1) exclusion of tobacco in our definition of “any SUD”; (2) removal of NDC codes primarily used to treat pain rather than opioid use disorder; and (3) removal of methadone NDC codes as these codes are thought to represent pain treatment, rather than opioid use disorder. One or more occurrence of a SUD diagnosis code or NDC code in OT, IP, LT, or RX files is coded as an SUD. Following CMS data book technical specifications, naltrexone—used to treat alcohol use disorder and opioid use disorder—is coded as alcohol use disorder when an alcohol use disorder diagnosis code is present, but coded as opioid use disorder in all other instances. “Any Substance Use Disorder” includes enrollees with at least one opioid, alcohol, cannabis, stimulant, or other SUD. “Other Substance Use Disorder” includes diagnosis codes for sedative, hallucinogen, caffeine, inhalant, unknown, or other SUD.

National Survey on Drug Use and Health. The National Survey of Drug Use and Health (NSDUH) asks respondents 12 and older about substance use and symptoms of substance use disorders, and those who exceed certain thresholds are classified as having a SUD. This analysis uses 2018/19 NSDUH data and includes Medicaid enrollees between the ages of 12 and 64. Although the NSDUH collects nationally representative data and asks each respondent about their substance use and symptoms, it may still underestimate SUD prevalence. NSDUH only collects data from people with an address–excluding those who are unhoused, institutionalized, or incarcerated – which is relevant because these populations may have higher rates of substance use disorders.

This work was supported in part by Well Being Trust. KFF maintains full editorial control over all of its policy analysis, polling, and journalism activities.

MM Curator summary

The article below has been highlighted and summarized by our research team. It is provided here for member convenience as part of our Curator service.

[MM Curator Summary]: A new study begins to quantify how much ED is used for mental health in multiple states.

Clipped from: https://oregoncapitalchronicle.com/2023/02/13/hundreds-of-thousands-of-medicaid-patients-seek-treatment-in-emergency-rooms/

A study by Oregon Health & Science University found that patients in Iowa, Nevada and Ohio had the highest rates of use, while Oregon was in the middle

Emergency rooms, like the one at Oregon Health & Science University, end up boarding mental health patients who have no where else to go. (Christine Torres Hicks/OHSU)

A new study shows that hundreds of thousands of low-income patients seek mental health care every year in emergency departments across the country rather than in clinics designed to treat them.

Those patients include thousands of Oregonians, the study’s lead author told the Capital Chronicle.

John McConnell, a health economist at Oregon Health & Science University, led the study, which he said was one of the first of its kind to use newly available Medicaid data to chart emergency department visits for mental illness. 

“Mental health is very important to the Medicaid program,” McConnell said. “Medicaid covers a disproportionate number of people with mental health conditions. It’s hard to really measure access to mental health care, so you can consider this a proxy for access to care.”

Published in the journal Health Affairs, the study looked at 12 million adults in 2018 on Medicaid, which covers one in four in Oregon and nearly as many nationwide. The researchers found that these patients in some states – Iowa, Nevada and Ohio – had the highest number of per-capita emergency department visits for mental health care, while patients in other states – Colorado, West Virginia and Arizona – sought emergency care for a mental health issues at the lowest rates nationwide.

Oregon fell in the middle.

McConnell said that probably reflects an emphasis in Oregon on keeping people on Medicaid out of emergency departments. Regionally based insurers, called coordinated care organizations, manage care for Oregon’s Medicaid patients. The state has pressured them to reduce the rate of ER visits for mental health care, especially among patients with severe and persistent conditions.

McConnell estimated that Medicaid patients in Oregon sought emergency mental health care up to 12,000 times in 2018.

“In a perfect world, we don’t want a lot of people to go to the ER to get their mental health care,” McConnell said. “It’s a place that takes all comers. It’s really designed for acute care. A lot of mental health treatment requires something more than an hour-long visit.”

Mental health treatment can take time and sometimes requires medication. Residential facilities and clinics are designed to treat these patients – and can do so successfully, experts say.

Although Oregon falls in the middle in the study, nationwide surveys have shown a high prevalence of mental illness in Oregon and a low access to treatment. This session, the Legislature is looking again at boosting funding to expand residential treatment capacity and attract more workers to the field.

The study did not analyze why the patients sought help in emergency departments rather than clinics or other facilities. But researchers said this is something for states to look at. 

“Do high rates of utilization for both ambulatory and emergency mental health care suggest a region under duress, or are they an indicator of high capacity and low quality? Or do they reflect idiosyncratic patient preference and provider coding practice?” the study asked.

Researchers found little correlation between visits for anxiety and schizophrenia or between visits for depression and suicide.

“These findings suggest that a ‘one-size-fits-all’ solution to improving mental health may be less effective than programs likely tailored to the local population’s needs,” the study said.

MM Curator summary

The article below has been highlighted and summarized by our research team. It is provided here for member convenience as part of our Curator service.

[MM Curator Summary]: The CA deal will be a huge lift for the startup towards its goal in monetizing its CBT app.

Clipped from: https://www.managedhealthcareexecutive.com/view/akili-laying-off-30-of-workforce

California Medi-Cal Contracts With Pear to Treat Stimulant Use Disorder

Medi-Cal, California’s Medicaid program, has contracted with Pear Therapeutics for members in 24 counties to participate in an outpatient program for stimulant use disorder.

A pilot program with the state of California’s Medicaid program, Medi-Cal, will allow eligible members to participate in a 24-week outpatient program to treat stimulant use disorder. The Recovery Incentives: California’s Contingency Management Program will utilize Pear Therapeutics to track and distribute incentives.

The program uses evidence-based treatment to provide motivational incentives to treat stimulant use disorder. The goal is to recognize and reinforce positive behavioral change. California has received federal approval for the use of contingency management (CM) as a benefit in the Medicaid program.

Julia Strandberg, MBA, chief commercial officer, Pear Therapeutics, praises California Medi-Cal decision.

“We applaud California’s DHCS for taking this important step to expand access to behavioral treatment to address the stimulant use disorder crisis that persists in California,” Julia Strandberg, chief commercial officer of Pear Therapeutics, said in a statement. “By working together, we will implement an innovative program that will reinforce individual positive behavioral change consistent with meeting treatment goals.”

The program is launching in 24 California counties in the first quarter of 2023. The 24-week outpatient program is also followed by six or more months of additional recovery support services. Motivational incentives will be in the form of low-denomination gift cards and the retail value will be determined per treatment episode.

Pear will deliver, implement, and manage the program through the electronic tracking and distribution of incentives to Medi-Cal members who participate in the program. The pilot program will inform the design and implementation of a statewide CM benefit through the Drug Medi-Cal Organized Delivery System.

California is not the first state to partner with Pear to fight addiction. In November, the Wisconsin Department of Health Services awarded the company funding to provide residents with access to Pear’s reSET and reSET-O, which treat substance use disorder and opioid use disorder, respectively.

Both reSET and reSET-O are FDA-authorized prescription digital therapeutics (PDTs) delivering cognitive behavioral therapy and indicated to improve outpatient treatment for substance use and opioid use disorders. PDTs use software to treat serious disease and once they are evaluated and authorized by regulators, they are used under the supervision of a prescribing clinician.

In Wisconsin, synthetic opioids, such as fentanyl, were identified in 91% of opioid overdose deaths and 74% of all drug overdose deaths, with fentanyl overdose deaths growing by 97% from 2019 to 2021.

The state is making reSET and reSET-O available in a variety of outpatient treatment settings.

“The state of Wisconsin is making a difference for those struggling with addiction by expanding access to evidence-based treatment and recovery services,” said Strandberg. “We have a shared goal to ensure that people living with substance and opioid use disorders have every opportunity for favorable outcomes for recovery.”

Earlier, Pear had partnered with the South Carolina Department of Corrections to provide both PDTs to women incarcerated at the Camille Griffin Graham Correctional Institution.

“Pear and the South Carolina Department of Corrections intend to integrate innovative clinically validated technologies into the treatment paradigm to combat addiction and support those at-risk,” Strandberg said. “Our prescription digital therapeutics are designed to help patients on the path to recovery while our clinician dashboard allows counselors to monitor patient progress.”

Both reSET and reSET-O have been studied in randomized controlled trials with the findings published in peer-reviewed medical journals. The studies found the PDTs have the potential to improve real-world health outcomes and decrease treatment costs.

A recent study in The American Journal of Addictions presented findings of a real-world observational analysis that demonstrated high rates of engagement, retention, and abstinence from substances for patients using the reSET treatment through 12 weeks.

MM Curator summary

The article below has been highlighted and summarized by our research team. It is provided here for member convenience as part of our Curator service.

[MM Curator Summary]: Nearly all states are trying things like increasing rates and expanding scope of practice to help deal with the BH workforce shortage.

Clipped from: https://healthpayerintelligence.com/news/how-state-medicaid-programs-address-the-behavioral-health-workforce-shortage

Over 70 percent of state Medicaid programs reported at least one strategy to incentivize provider participation in Medicaid, helping to alleviate the behavioral health workforce shortage.

By Victoria Bailey

January 16, 2023 – State Medicaid programs have implemented or plan to implement strategies to address the behavioral health workforce shortage, including increasing reimbursement rates and reducing administrative burden, according to an issue brief from the Kaiser Family Foundation (KFF).

The COVID-19 pandemic exacerbated mental health issues and increased the need for behavioral healthcare. However, workforce challenges have made it difficult for people to access care.

Data from 2020 revealed that around 39 percent of Medicaid beneficiaries were living with a mental health or substance use disorder. Meanwhile, only 36 percent of psychiatrists accept new Medicaid patients.

KFF surveyed state Medicaid officials about their strategies that addressed the behavioral health workforce shortage in fiscal year (FY) 2022 and the strategies they plan to implement in FY 2023. Forty-three states and the District of Columbia responded to the survey, with response rates varying by question.

State strategies fell into four areas: increasing reimbursement rates, extending the behavioral health workforce, reducing administrative burden, and incentivizing provider participation in Medicaid.

Reimbursement gaps often limit access to care, especially for Medicaid beneficiaries. Psychiatrists receive lower Medicaid reimbursement than primary care providers. In addition, overall Medicaid payment rates may be lower than other payers.

States have opportunities to increase reimbursement rates in fee-for-service (FFS) Medicaid and managed care organizations (MCOs).

Nearly two-thirds of responding states (28 of 44) implemented FFS payment rate increases in FY 2022 or plan to in FY 2023.

Many states used the temporary funding provided through the American Rescue Plan Act (ARPA) that boosted the Medicaid match rate for home and community-based services (HCBS) to increase behavioral health provider rates.

In some states, specific provider types received payment rate increases, such as applied behavioral analysis or those providing residential-level care for substance use disorders.

Other states implemented broader increases. For example, Oregon instructed its Medicaid coordinated care organizations to raise rates by 30 percent for providers who receive 50 percent or more of their revenue from Medicaid and 15 percent for those who receive less than 50 percent of their revenue from Medicaid.

Strategies to expand the workforce were common, with 33 out of 38 responding states reporting they had at least one strategy in place or planned for FY 2023. The top strategy reported was adding peer or family specialists as providers who can bill without a supervising practitioner.

States also reported extending direct reimbursement privileges to other types of mental health practitioners, such as clinical social workers. In addition, almost two-thirds of states reimbursed services delivered by license-eligible individuals practicing under supervision in FY 2022.

Providers can experience significant administrative burden when managing prior authorization, documentation requirements, and lengthy credentialing processes.

Around 75 percent of responding states reported at least one strategy to reduce provider administration burden in FFS and MCOs. Many states said they had sought behavioral health provider feedback on administrative processes, while multiple states reported plans to implement centralized or standardized provider credentialing in FY 2023.

Certain state Medicaid programs have more flexibility than others regarding reducing administrative burden. For example, one state shared how their behavioral health authority regulates documentation, meaning streamlining the process would require collaboration between the Medicaid agency and the authority.

Provider participation in Medicaid programs may be slim due to reimbursement gaps and delays, but implementing prompt payment policies could help incentivize participation.

Two-thirds of reporting states had prompt payment policies in FFS and MCOs in FY 2022. However, less than one-fifth of states reported providing financial incentives to encourage providers to participate in physical and behavioral health integration.

The brief found that state Medicaid programs’ efforts to support the behavioral health workforce are on par with federal efforts. The Consolidated Appropriations Act passed in December 2022 authorized funding for new psychiatry residency positions and included provisions to boost the number of providers authorized to prescribe medications for opioid use disorder.