Cindy Parks Thomas

The US is experiencing an epidemic of opioid misuse and mortality. Effective treatments are available, including medications for opioid use disorders (MOUD), but they are greatly underused due to a variety of barriers. In response, some US hospitals have established programs to identify emergency department (ED) patients with opioid use disorders (OUD) and begin treatment with MOUD ("ED induction"). For this model to be widely adopted, financial sustainability for hospitals is critical. Little is known about the financial aspects of ED-based treatment models, including insurance billing and reimbursement. Our study addressed the following questions about ED-based induction of OUD treatment: (1) Which components of this model are billable to insurers? (2) How do hospitals fund the components that are not billable? (3) Does ED-based induction generate savings that could help fund that service? We conducted a qualitative study, involving semi-structured interviews with officials at selected US hospitals. Potential interviewees were identified using a snowball sampling approach. We conducted 12 interviews across 10 states, mostly with urban teaching hospitals. Key findings include, (1) medication costs are often billable to insurers, but costs of key para-professional staff like peer navigators are not, requiring the hospital to absorb their salaries. Even some billable costs are reimbursed at low rates which challenge sustainability. (2) To fund non-billable components, hospitals typically rely on time-limited grant funding, including the federal 340B drug rebate program. (3) Several interviewees anticipated cost savings to their hospitals from reduced use of ED services by patients who had no (or low-paying) insurance. These findings indicate that some hospitals are able to sustain ED-based induction of MOUD using time-limited grant funding. However, wider dissemination of this model will likely require more stable funding streams, such as Medicaid reimbursement, paying adequate rates, and coverage of personnel.

Medicaid managed care plans (MCPs) and states play essential roles in supporting access to high-quality opioid use disorder (OUD) treatment services. This study aimed to identify MCP and state-level policies associated with better plan performance on indicators of quality OUD treatment. Publicly available data on Medicaid MCPs' profit status, behavioral health contracting arrangements, market share, buprenorphine prior authorization and quantity limit policies and state Medicaid policies were linked with plan-level measures of OUD treatment quality from the National Committee on Quality Assurance (n = 107). Regression analyses were used to examine associations between Medicaid MCP characteristics, MCP buprenorphine policies, and features of the state policy environment with plan-level rates of OUD treatment initiation and engagement. The average OUD treatment initiation rate was 59.6 % and engagement was 30.9 %. MCPs with large market share had initiation and engagement rates 4.66 and 4.54 percentage points lower, respectively, than plans with small market share. Plans operating in states with 1115 SUD waivers had initiation and engagement rates 7.75 and 8.55 percentage points higher, respectively, than plans in states without waivers. Engagement rates among plans that required prior authorization for buprenorphine were 4.53 percentage points lower than plans without this restriction. Findings suggest state and MCP policies are important pathways to improve initial and sustained OUD treatment. Further research into these relationships is needed.

Evidence-based, patient-centered treatment for alcohol use disorder (AUD) can include pharmacotherapy with naltrexone, acamprosate, or disulfiram; however, these medications are rarely used. Medicaid managed care plans (MCPs) manage health services for nearly 80% of Medicaid enrollees and are the largest payer for addiction treatment services. Little is known about Medicaid MCP policies for AUD medications. To describe Medicaid MCPs' coverage and management of acamprosate, naltrexone, and disulfiram for AUD and examine associations of plan characteristics and state policies with medication coverage. In this cross-sectional study, a content analysis was performed of 2021 insurance benefit data for 241 comprehensive Medicaid MCPs in states using Medicaid managed care, as well as secondary sources. Data were analyzed from May to August 2024. Medicaid MCP-reported medication coverage and utilization management requirements (eg, prior authorization, quantity limit requirements) for acamprosate, disulfiram, and oral and injectable naltrexone together and for each medication separately. Independent variables included plan characteristics (profit status, market share) and the state policy environment in which plans are embedded (Section 1115 substance use disorder waiver, state-defined preferred drug list). Regressions examined associations of plan characteristics and state policies with medication coverage. In this cross-sectional content analysis of 241 comprehensive Medicaid MCPs in 2021, 217 (90.0%) covered at least 1 medication for AUD: 132 (54.7%) covered acamprosate, 203 (84.2%) covered oral naltrexone, 175 (72.6%) covered injectable naltrexone, 152 (63.0%) covered disulfiram, and 103 (42.7%) covered all 4 medications. Prior authorization and quantity limits were rarely applied, except for injectable naltrexone, for which 75 plans (42.8%) imposed at least 1 of these utilization management requirements. This study suggests that efforts to expand AUD medication prescribing may be limited by gaps in health insurance coverage. Medicaid MCPs and states can support AUD medication utilization by covering these medications without applying utilization management strategies.

To examine whether Medicaid managed care plan (MCP) utilization management policies for buprenorphine-naloxone and injectable naltrexone are related to key state Medicaid program policy decisions. We abstracted data on state Medicaid regulatory and policy information from publicly available sources and publicly available insurance benefit documentation from all 241 Medicaid MCPs operating in 2021. In this cross-sectional study, we used bivariate and multivariate analyses to examine whether Medicaid MCP prior authorization and quantity limits on receipt of buprenorphine and injectable naltrexone were associated with key state Medicaid choices to leverage federal funds to expand coverage and eligibility (Medicaid expansion, 1115 waivers) and to regulate Medicaid MCPs (uniform preferred drug lists, medical loss ratio remittance). Models were adjusted for MCP characteristics, including profit status, behavioral health contracting arrangement, National Committee for Quality Assurance accreditation, size, market share, and state opioid overdose death rates. Average marginal effects (AME) were reported. Utilization management was common among MCPs, and restrictions were more commonly applied to buprenorphine than injectable naltrexone, despite its higher cost. States that required MCPs to comply with utilization management policies stipulated in a uniform preferred drug list were more likely to require prior authorization for buprenorphine (AME: 0.29, 95% CI: 0.15-0.42) and injectable naltrexone (AME: 0.25, 95% CI: 0.12-0.38). MCPs in states that required plans to pay back earnings above a certain threshold were less likely to require prior authorization for buprenorphine (AME: -0.30, 95% CI: -0.43 to -0.18). Restrictions on medications for opioid use disorder are widespread among MCPs and vary by medication. State Medicaid regulatory and policy characteristics were strongly linked to MCPs' utilization management approaches. State Medicaid policy and contracting approaches may be levers to eliminate utilization management restrictions on medications for opioid use disorder.

Opioid use disorder (OUD) is a leading cause of preventable death and injury nationwide. Efforts to increase the use of medication for opioid use disorder (MOUD) are needed. In 2017, Washington State implemented a Hub and Spoke (HS) model of care with the primary goal of expanding access to MOUD. We examined changes in MOUD utilization among Washington State Medicaid beneficiaries before and after HS implementation.
We used Medicaid claims data to examine longitudinal changes in MOUD use for beneficiaries with OUD. We conducted a comparative interrupted time series analysis to examine the association between HS policy implementation and rates of MOUD utilization, overall and by type of medication.
Between 2016 and 2019, a period of increasing OUD prevalence, rates of MOUD utilization among Washington Medicaid beneficiaries increased overall from 39.7 to 50.5. Following HS implementation, rates of MOUD use grew at a significantly greater rate in the HS cohort than in the non-HS cohort (β=0.54, SE=0.02, p< 0.0001, 95% CI 0.49, 0.59). Analyses by medication type show that this rate increase was primarily due to buprenorphine use (β= 0.61, SE= 0.02, p< 0.0001, 95% CI 0.57, 0.65).
Improved systems of care are needed to make MOUD accessible to all patients in need. The Washington HS model is one strategy that may facilitate and expand MOUD use, particularly buprenorphine. Over the study period, Washington State saw increased use of buprenorphine, which was an emphasis of their HS model.