Best Practices and Barriers to Engaging People with Substance Use Disorders in Treatment. INTRODUCTION

03/06/2019

The 2015 National Survey on Drug Use and Health (NSDUH) found that 20.8 million people aged 12 years or older (7.8 percent of the United States population) had a substance use disorder (SUD) in the previous year.[1] Evidence-based SUD treatments such as behavioral therapies and medication are effective, as evidenced by hundreds of rigorous efficacy trials and millions of individuals in recovery. However, despite the great need for and efficacy of these treatments, rates of treatment receipt are extremely low. In 2015, only 3.7 million people received SUD treatment--a number that has not increased significantly since 2002.[1, 4] Moreover, once individuals enter treatment, they tend to drop out before obtaining meaningful benefits. Only about 48 percent of patients who enter SUD treatment actually complete it,[5] even as research has shown that engagement in treatment improves treatment outcomes.[28]

Among other initiatives, one way that federal, state, and privately funded health care systems have tried to address the low rates of initiation and engagement in SUD treatment is through performance metrics. Federal, state, and private payers have incorporated measures endorsed by the National Quality Forum into their programs to track performance among health plans. One such performance measure is Initiation and Engagement of Alcohol and Other Drug Dependence Treatment (IET).

SUD TREATMENT ACCESS
In 2015, only 18% of the population with SUD received treatment--a number that has not increased significantly since 2002.

The rate of IET varies significantly among health plans, suggesting that some plans are more effective at initiating and engaging their members in SUD treatment than others.[6] Overall national rates of initiation and engagement have not shown consistent improvement over time. In commercial and Medicaid health plans, respectively, rates for initiation have hovered between 39.1 percent and 49.0 percent, and rates of engagement have stayed between 9.6 percent and 16.2 percent throughout the past decade, with no sustained improvement.[29]

In response to the stagnating rates of initiation and engagement, the U.S. Department of Health and Human Services (HHS) Office of the Assistant Secretary for Planning and Evaluation (ASPE) initiated a study to determine how higher-performing health plans improve initiation and subsequent engagement in SUD treatment. This report synthesizes the results of quantitative analyses of commercial health plan data and qualitative interviews with Medicaid and commercial plans, to determine health plan and other factors that influence initiation and engagement in SUD treatment. We provide background gleaned from the literature, address the methods for both the quantitative and qualitative analyses, present the results of that research, and offer a synthesis of the findings, including an overview of health plan and related factors that influence initiation and engagement.

Epidemiology of Substance Use and Substance Use Disorders in the United States

Substance use and SUDs are a persistent public health concern. The 2015 NSDUH found that approximately 138.3 million Americans aged 12 years or older reported past 30-day use of alcohol, and 27 million reported past 30-day use of illicit drugs (Table 1).[1] National prevalence rates also are high for SUDs. Approximately 20.8 million Americans aged 12 years or older were classified with an SUD in 2015. Among those identified, 7.7 million had an illicit drug use disorder; 15.7 million had an alcohol use disorder; and 2.7 million were diagnosed with both an alcohol and an illicit drug SUD (Table 1).[1] Individuals aged 18-25 years had the highest rates of SUDs in 2015, with 18.2 percent of that age group having an SUD in the past year.[2] A separate study that examined rates of SUDs in older adults estimated that, by 2020, approximately 5.7 million adults aged 50 years and older will have an SUD.[30]

TABLE 1. Summary of 30-Day Prevalence Rates of Substance Use and Annual Prevalence Rates of Dependence or Abuse of Alcohol and Illicit Drugs Among People Aged 12 Years and Older in 2015
Substance Use in the Past 30 Days Dependence or Abusea
N
(in millions)
%
of population
N
(in millions)
%
of population
Any substance --- --- 20.8 7.8
Alcohol 138.3 51.7 15.7 5.9
Illicit drug 27.1 10.1 7.7 2.9
Alcohol and illicit drug --- --- 2.7 1.0
SOURCE: 2015 NSDUH.[1]
  1. The 2015 NSDUH still used the terms abuse and dependence rather than the umbrella term substance use disorder with gradations of severity that was adopted in the Diagnostic and Statistical Manual of Mental Disorders, 5th Edition (DSM-V). Whenever this report provides information from the 2015 NSDUH that specifies abuse or dependence, the report uses those terms. If the NSDUH provided less granular information about disorders generally, this report refers to substance use disorders.

Epidemiology of Alcohol Use and Alcohol Use Disorders

Alcohol use, including binge drinking and heavy alcohol use, is common in the United States. Approximately 138.3 million Americans aged 12 years or older reported past 30-day use of alcohol in 2015.[1] Approximately 66.7 million people, or one in four individuals aged 12 years or older in 2015, engaged in past 30-day binge drinking, with binge drinking defined as four or more drinks on one occasion for females and five or more drinks for males.[1] Heavy alcohol use, which is defined as binge drinking on 5 or more days in the past 30 days, was present in an estimated 17.3 million individuals aged 12 years or older, or 6.5 percent of the population, in 2015.[1] In that same year, approximately 15.7 million Americans had an alcohol use disorder.[1]

Alcohol use and alcohol use disorders are more pronounced in certain demographic groups, including individuals aged 18-25 and males, with rates of past-month alcohol use highest in the non-Hispanic White population and alcohol use disorders highest in Native Americans (Table 2).[1] There also is evidence that women's rates of alcohol use are heavily influenced by pregnancy status. In 2015, approximately 54.8 percent of non-pregnant women of childbearing age (15-44 years old) consumed alcohol in the past month, whereas those who were pregnant had past-month drinking rates of 9.3 percent. Rates were highest (16.4 percent) among those in the first trimester, followed by the second (6.1 percent) and third (4.3 percent) trimesters.[2]

TABLE 2. Alcohol Use and Disorder Prevalence in 2015 by Selected Demographic Characteristics
Characteristics Past 30-Day
Alcohol Use, %
Alcohol Use
Disorder, %
Binge
Drinking, %
Heavy Alcohol
Use, %
Age, years
12-17 9.6 2.5 5.8 0.9
18-25 58.3 10.9 39.0 10.9
26 and older 55.6 5.4 24.8 6.4
Sex
Male 56.2 7.8 29.6 8.9
Female 47.4 4.1 20.5 4.2
Race/ethnicity
Non-Hispanic White 57.0 6.1 26.0 7.6
Non-Hispanic Black 43.8 4.9 23.4 4.8
Asian 39.7 3.2 14.0 2.2
Native Hawaiian or other Pacific Islander 33.8 5.4 17.8 3.0
American Indian and Alaska Native 37.9 9.7 24.1 4.7
Two or more races 42.8 6.2 22.9 6.8
Hispanic 42.4 6.4 25.7 4.8
SOURCE: 2015 NSDUH.[2]

Epidemiology of Illicit Drug Use and Illicit Drug Use Disorders

In 2015, approximately 27.1 million Americans reported past 30-day illicit drug use, including those who misused prescription medication. The prevalence rate for past 30-day illicit drug use corresponds to one in every ten Americans or about 10.1 percent of the United States population.[1] Demographic groups with the highest rates of recent illicit drug use included those aged 18-25 years, males, and individuals identifying as being of two or more races (Table 3). Among these groups, there is evidence that women's rates of illicit drug use may be heavily influenced by age. Approximately 12.5 percent of non-pregnant women of childbearing age (15-44 years) engaged in past-month illicit drug use. This percentage was nearly 50 percent higher than the percentage for the female population overall. Approximately 4.7 percent of pregnant women (15-44 years old) reported illicit drug use, with rates highest among those in the second trimester (6.4 percent).[2]

In 2015, 7.7 million Americans had an illicit drug use disorder, constituting nearly 3 percent of the population aged 12 years or older.[2] It is estimated that 9.9 percent of the United States population will develop a drug use disorder at some point during their lifetimes.[31] The highest prevalence rates were in people between the ages of 18 and 25, males, and those identifying as of two or more races (Table 3).

TABLE 3. Illicit Drug Use and Disorder Prevalence in 2015 by Selected Demographic Characteristics
Characteristics Past 30-Day Illicit
Drug Use, %
Illicit Drug Use
Disorder, %
Age
12-17 years 8.8 3.4
18-25 years 22.3 7.2
26 years and older 8.2 2.1
Sex
Male 12.5 3.8
Female 7.9 2.0
Race/ethnicity
Non-Hispanic White 10.2 2.8
Non-Hispanic Black 12.5 3.5
Asian 4.0 1.2
Native Hawaiian or other Pacific Islander 9.8 4.5
American Indian and Alaska Native 14.2 4.1
Two or more races 17.2 4.9
Hispanic 9.2 3.0
SOURCE: 2015 NSDUH.[2]

Opioid use and opioid use disorders (OUDs), whether related to heroin or to prescription opioid use, are among the most problematic substance use trends in the United States today. Since 1999, opioid-related overdose deaths in the United States have quadrupled, with more than 15,000 individuals experiencing prescription drug-related overdose deaths in 2015.[3] Evidence shows that, among those with commercial insurance, professional charges for OUD treatment rose by more than 1,000 percent from 2011 to 2015 (from $71.66 million to $721.80 million). Total annual charges in 2015 for a person diagnosed with an OUD were 556 percent higher than the average for all patients.[32]

Heroin Use and Heroin Use Disorders

Rates of heroin use have increased in recent years, from a relatively stable rate of 0.2 percent of the population between 2002 and 2011 to 0.3 percent starting in 2012 (Table 4).[1] In 2015, approximately 0.3 million Americans aged 12 years and older reported past-month heroin use, and about 828,000 people reported past-year use.[1] The 2015 NSDUH, however, revealed a dramatic reduction in the rate of new heroin users aged 12 years or older. In 2013, an estimated 169,000 individuals began engaging in heroin use in the year prior to being interviewed, and this number increased to 212,000 in 2014. The incidence of new users in 2015, however, decreased to 135,000. Past-year initiation rates also decreased as a percentage of past-year users (24.9 percent in 2013, 23.1 percent in 2014, 16.3 percent in 2015).[2, 33] Young adults aged 18-25 years are more likely than any other age group to use heroin. In 2015, 0.6 percent of young adults aged 18-25 years reported past-year heroin use,[1] with 57,000 initiating heroin use in 2015.[2]

The prevalence of heroin use disorders also has grown in recent years (Table 4). In 2015, about 0.6 million people or 0.2 percent of the population aged 12 years or older had a heroin use disorder in the past year.[1] This was a statistically significant increase from 2010, when 0.1 percent of the population had a heroin use disorder.[4] Young adults were more likely than any other age group to be dependent on heroin (0.4 percent in 2015).[1] Past-year heroin use disorder prevalence among those aged 18-25 years was 585,000 in 2015 (Table 4).[2] Among adults aged 26 years and older, the prevalence of heroin dependence or abuse was 430,000 in 2015, or 0.2 percent of the population.[2]

TABLE 4. Percentages of Heroin Use Disorders and Past-Year Heroin Use Over Time
Characteristic Age, Years 2002 2010 2011 2012 2013 2014 2015
Past-year heroin use 12+ 0.2a 0.2 0.2 0.3 0.3 0.3 0.3
18-25 0.4a 0.6 0.7 0.8 0.7 0.8 0.6
Heroin use disorder 12+ 0.1 0.1 0.2 0.2 0.2 0.2 0.2
18-25 0.2a 0.3 0.4 0.5 0.5 0.5 0.4
SOURCE: 2015 NSDUH.[1]
  1. Significant at the 0.05 level compared with 2015.

Heroin use disorder rates have a strong, positive correlation with heroin-related morbidity and overdose deaths over time.[34] Among individuals with SUDs, heroin users have the highest prevalence of hospitalization (a 30 percent annual rate between 2009 and 2013).[35] As dependence rates have increased, so have rates of heroin-related overdoses. There were nearly 13,000 heroin overdose deaths in 2015.[36] The increase in overdoses has affected individuals across a range of sociodemographic groups. Between 2010 and 2012, heroin-related overdoses increased 86 percent to 102 percent for every age group. In 2012, males had a heroin-related overdose rate of 3.3 per 100,000, which was a 99 percent increase from 2010.

In 2015, males aged 25-44 years had the highest death rates at 13.2 per 100,000--an increase of 22.2 percent from 2014.[36] Women experienced a 110.9 percent increase in heroin-related overdoses between 2010 and 2012. Rates of heroin-related overdose also have increased for each racial group in recent years. For both the non-Hispanic White and Hispanic White populations, heroin-related overdoses increased by approximately 102 percent between 2010 and 2012. The African-American community experienced an 89.3 percent increase in heroin-related overdoses for the same time period.[37]

HEROIN-RELATED OVERDOSES
Between 2010 and 2012, heroin-related overdoses increased 86% to 102%.

Prescription Opioid Misuse and Disorders

In 2015, 3.8 million individuals aged 12 years or older in the United States (1.4 percent of the population) reported current misuse (non-medical use) of prescription opioids. The number of individuals who reported past-year prescription opioid misuse was 12.5 million or 4.7 percent of the population. In that year, hydrocodone medications were the most frequently misused category of prescription opioids--misused by 2.7 percent of those aged 12 years or older in 2015--followed by oxycodone medications (1.6 percent). In 2015, a total of 2.1 million individuals initiated prescription opioid misuse, and 2.0 million individuals had a prescription OUD (both 0.8 percent of those aged 12 years or older).[2] According to the NSDUH, the demographic groups with the highest prevalence of prescription opioid misuse in 2015 included young adults aged 18-25 years, males, and individuals identified as being two or more races. The NSDUH did not report rates of prescription OUD other than by age, with those aged 18-25 years having the highest rates of such disorders (Table 5).

TABLE 5. Prescription Opioid Misuse and Disorder Prevalence in 2015 by Selected Demographic Characteristics
Characteristics Past 30-Day Prescription
Opioid Misuse, %
Prescription OUD, %
Age
12-17 years 3.9 0.5
18-25 years 8.5 1.2
26 years and older 4.1 0.7
Sex
Male 5.3 --
Female 4.0 --
Race/ethnicity
Non-Hispanic White 4.8 --
Non-Hispanic Black 4.4 --
Asian 1.8 --
Native Hawaiian or other Pacific Islander 5.4 --
American Indian and Alaska Native 5.6 --
Two or more races 8.4 --
Hispanic 5.0 --
SOURCE: 2015 NSDUH.[2]

Nearly half of all opioid overdose deaths involve a prescription opioid. Such deaths have quadrupled since 1999 and, in 2015, more than 15,000 individuals experienced prescription drug-related overdose deaths.[3] Rudd et al. (2016) examined trends in both heroin and prescription opioid-related overdose death rates across 28 states from 2010 through 2015.[38] Rates of death from synthetic opioids other than methadone increased and, although many of these deaths involved prescription opioids, the increase seems to have been driven by illicitly manufactured fentanyl. In 2015, death rates from non-methadone synthetic opioids were greatest in males aged 25-44 years.[38]

Substance Use Disorder Treatment Access and Uptake in the United States

Evidence-based treatment can effectively help people recover from SUDs.[39] Recent analyses indicate that the addition of a single substance abuse treatment facility in a county may be associated with declines in rates of drug-induced mortality and many types of violent and financially motivated crimes, with an additional treatment facility reducing social costs attributed to all crime by approximately $700,000 annually. SUD treatment also has been shown to result in meaningfully reduced rates of crime, with a 10 percent relative increase in the SUD treatment rate at an average cost of $1.6 billion yielding a crime reduction benefit of $2.5-$4.8 billion.[40] Other studies show that, for every dollar spent on SUD treatment, four dollars are saved in other health care costs.[12]

Many Americans in need of SUD treatment do not receive it. According to the 2015 NSDUH, approximately 21.7 million or 8.1 percent of Americans aged 12 years or older were identified as needing SUD treatment.[1] Yet in 2015, only 3.7 million Americans aged 12 years or older, or 14.0 percent of the United States population that needed treatment, received any substance use treatment for any kind of problem related to substance use. Among the 21.7 million individuals who needed substance use treatment, only 2.3 million people (10.8 percent) received specialty treatment.[1] According to the NSDUH, when substance use treatment was utilized, most individuals surveyed sought care in self-help groups (1.9 million) and outpatient rehabilitation programs (1.75 million). They less commonly obtained care in outpatient mental health centers, inpatient rehabilitation facilities, hospital-based inpatient programs, private doctor's offices, or emergency departments.[2]

DEATHS FROM ALCOHOL
Alcohol misuse and alcohol use disorders result in an estimated 88,000 deaths annually.

Alcohol misuse and alcohol use disorders result in an estimated 88,000 deaths annually,[41] and excessive alcohol consumption is associated with adverse health and social consequences, including liver cirrhosis, certain cancers, fetal alcohol spectrum disorder, unintentional injuries, and violent behaviors.[42] Individuals with an alcohol use problem represent a heterogeneous population, which necessitates the use of personalized treatment approaches such as medication and counseling.[43] Medication-assisted treatment (MAT) incorporating pharmacotherapy and, ideally, psychosocial treatment, is an evidence-based treatment for alcohol use disorders; medications used include acamprosate, disulfiram, or naltrexone.[44] In 2015, 2.2 million people aged 12 years or older (0.8 percent of the population) received any type of past-year treatment for an alcohol use problem. Among these individuals, treatment was most commonly reported as occurring, non-exclusively, in self-help groups (57.5 percent), outpatient (33.5 percent) or inpatient (28.1 percent) rehabilitation facilities, outpatient mental health centers (26.6 percent), and inpatient hospitals (20.1 percent).[a] In 2015, approximately 1.4 million individuals reported receipt of specialty treatment in the past year for an alcohol use problem. This figure represented only 8.2 percent of the nearly 16.4 million individuals reported to need treatment for an alcohol use disorder. In 2015, only 12.9 percent and 7.8 percent of individuals who needed treatment and identified as non-Hispanic Black and non-Hispanic White, respectively, received it.[2]

According to the NSDUH, in 2015, 22.4 percent and 17.4 percent of individuals receiving substance use treatment in the past year cited prescription opioid abuse or heroin use, respectively, as their reason for treatment.[2] Treatment for OUDs, whether related to heroin use or prescription opioid misuse, is critical. In addition to the devastation caused by overdose, opioid use can have other serious consequences. For example, a longitudinal study examining the 27-year outcomes of heroin users found that heroin use predicted a 3-fold to 4-fold excess risk of premature death, even when substance abuse was not sustained.[45] In 2013, it is estimated that OUDs cost the United States more than $78 billion in health care, criminal justice, and lost productivity costs.[46, 47] Early and effective treatment is important.

Evidence-based treatment options for both prescription opioid and heroin use disorders include MAT with methadone, buprenorphine, or naltrexone, as well as behavioral therapies including cognitive behavioral therapy. Results for 18-month treatment outcomes from the Prescription Opioid Addiction Treatment Study found that, across ten study sites, nearly half of all study participants received MAT. Of those initiating treatment, 40 percent received buprenorphine, whereas only 6 percent received methadone treatment. Of prescription opioid users seeking treatment, 34 percent were engaged in psychosocial services and 40.9 percent reported participation in self-help groups.[48]

Individuals with OUDs are not homogeneous. Different treatment approaches may be required, depending on the substance used and other individual characteristics. For example, one study found that individuals with a history of misusing prescription opioids were more likely to complete a substance use treatment program than were heroin users or individuals who engaged in combined opioid analgesic and heroin use.[49] Studies also suggest that individuals using prescription opioid analgesics may have better treatment outcomes with buprenorphine than individuals using heroin who receive similar treatment.[49, 50] Issues such as these indicate a need for individualized, patient-centered treatment.

Factors Influencing Participation in Treatment

Because so many individuals with SUDs do not obtain access to treatment, some exploration of factors that influence initiation and engagement in treatment is necessary.

Research shows that many factors may contribute to patients' initiation and engagement in treatment, including: (1) individual; (2) provider; (3) health plan; and (4) market and environmental factors. Figure 1 conceptualizes how multiple factors identified in the literature can affect this process.

FIGURE 1. Theoretical Model to Explain Participation in SUD Treatment
Health Plan Factors:
  • Benefit design
  • Provider network adequacy
  • Reimbursement design
  • Care models (chronic or acute care models and care management)
  • Quality improvement programs
Market/Environmental Factors:
  • Provider availability
  • State policies
  • Medicaid policies
  • Attitudes toward SUD treatment including MAT
  • Performance metrics
  • Regulations, credentialing, and certifications
  Initiation and Engagement in Treatment  
Individual Factors:
  • Attitudes and beliefs toward SUD treatment need and efficacy
  • Type of SUD
  • Use of MAT
  • Co-occrring mental and physical health conditions
  • Sociodemographic factors
  • Out-of-pocket expenses
Provider Factors:
  • Wait times
  • Ease of use (proximity, treatment time, enjoyment of pain of treatment, care transitions)
  • Efficacy of treatment used
  • Cost of treatment
  • Outreach
  • Referring provider characteristics (knowledge, attitude, care coordination capacity)

We examine in greater detail below factors affecting treatment participation that have been identified or studied in the past 5 years.

1. Individual Factors

Research has shown that individual patient characteristics--including individual beliefs, sociodemographic characteristics, types of substance use and substance delivery modality, treatment experience, co-occurring mental illness, cognitive functioning, and patient activation --may influence treatment initiation and engagement.

Individual beliefs. Individual factors, including beliefs, play a large role in an individual's decision about whether to seek treatment. The Surgeon General's Report on Alcohol, Drugs and Health stated that "stigma has created an added burden of shame that has made people with SUDs less likely to come forward and seek help" (p. v).[12] Research shows that the vast majority of people do not seek treatment because of attitudinal or belief barriers (e.g., lack of perceived need, concerns about stigma, doubts about efficacy).[51] For example, the 2015 NSDUH found that, of the group identified as needing specialty treatment, only 4.6 percent personally felt a need for treatment, and only 1.6 percent of the group needing treatment actually attempted to enter into services. Nearly 95.4 percent of all individuals identified as having a need for SUD treatment did not feel that treatment was necessary.[2]

Sociodemographic characteristics. Individual patient characteristics and sociodemographic factors such as sex, age, race/ethnicity, education, and insurance may influence decisions to initiate and engage in SUD treatment services. This topic has been studied extensively, and we briefly summarize the resulting findings below.

  • Women may be less likely than men to engage in SUD treatment.[7, 8, 9, 10]

  • Studies are mixed regarding the effects of age on initiation and engagement, with some studies showing older age to be beneficial,[7, 52, 53] others younger age,[9] and some no effect of age.[54]

  • Studies examining racial or ethnic differences associated with treatment initiation and engagement also produce varied results, including poorer initiation among Black and Hispanic populations compared with White populations, and higher rates of initiation for Native American and White patients than for other racial and ethnic groups.[7, 54] Similarly, several studies show that, compared with the non-Hispanic White population, Black and Hispanic populations may have lower rates of treatment engagment.[7, 42, 55, 56] Findings related to treatment continuation also identify somewhat similar results, depending on the substance used.[55]

  • Education level also influences treatment initiation and engagement for all racial and ethnic groups, with lower levels of formal educational attainment associated with failure to initiate and engage in treatment.[54, 55]

  • Having health insurance also is a predictor of engagement in substance use treatment. For example, individuals who were insured had 1.4 times the odds of receiving alcohol dependence treatment compared with their uninsured peers.[9]

CO-OCCURRENCE
A total of 8.1 million Americans aged 18 or older have both a past-year SUD and a mental disorder.

Substance use and treatment experience. The type of substance use, the route of ingestion, and history of SUD treatment also may influence treatment initiation and engagement.

  • Although the evidence is mixed and other factors may influence the results:

    • Compared with individuals abusing heroin, individuals who abuse prescription opioids are more likely to engage in treatment.[57]

    • Individuals engaged in alcohol abuse may be more likely to engage in treatment compared with those who have heroin dependence.[55]

    • Individuals with alcohol or cocaine use disorders may delay treatment longer than individuals with other types of SUDs.[54]

  • Substance users who injected opioids were less likely to complete treatment than those who did not inject,[49] and individuals who never used opioids via a non-recommended route (e.g., injection or snorting) were more likely to continue in treatment and abstain from illicit opioid use in the final 3 weeks of a 12-week buprenorphine treatment program.[52]

  • A prior history of SUD treatment may be associated with delays in the initiation of treatment for current needs.[52, 54]

Co-occurring mental illness and SUD. Co-occurring mental health issues are not uncommon in the population of those with SUDs, with 8.1 million Americans aged 18 or older having both a past-year SUD and a mental disorder. This represents more than 40 percent of adults with an SUD and has repercussions for treatment, including initiation and engagement.[2] Studies examining the co-occurrence of psychiatric conditions and SUDs suggest that dual diagnosis may complicate treatment initiation and engagement.[11, 52]

Treatment initiation in those with co-occurring mental illness may be complicated by several factors. A study by Brown and colleagues examined treatment initiation in a sample of adults with serious mental illness diagnoses including schizophrenia, schizoaffective disorder, major depression, and bipolar disorder.[11] Researchers defined treatment initiation as completing a pretreatment intake assessment, which required two in-person visits over the course of 2 weeks. The study results indicated that, unlike the general population, males with serious mental illness were 54 percent less likely than their female peers to initiate treatment. Brown et al.[11]also found that the specific serious mental illness diagnosis may influence initiation of treatment. Compared with participants with other serious mental illness diagnoses, study participants with schizophrenia spectrum diagnoses were less likely to initiate treatment (odds ratio = 0.44). Recent drug use also may be a factor in whether individuals with serious mental illness initiate treatment.[11]

Predictors of engagement may differ from predictors of initiation for individuals with serious mental illness. Brown et al.[11] found that, although patient characteristics and mental illness diagnoses may influence initiation, these variables did not predict engagement in SUD treatment (defined as attending three or more treatment sessions). Rather, engagement was predicted by the presence of current drug dependence (compared with recent history of drug dependence), patients' positive feelings toward family members, and having a recent arrest. Dreifuss et al.[52] found that the co-occurrence of an SUD and major depression was associated with improved treatment engagement and outcomes for individuals receiving buprenorphine/naloxone treatment for prescription opioid dependence. An example of the interaction of individual factors is suggested by the fact that the presence of both a mental disorder and SUD may be more prevalent in women--a group that has lower overall rates of engagement in SUD treatment.[58]

Co-occurring SUD and reduced cognitive functioning. Cognitive function may be another significant predictor of patient engagement. One study compared rates of therapy session attendance for patients with an SUD with or without cognitive impairment. Those with cognitive impairment were significantly less likely to attend all of their group therapy sessions compared with their peers without cognitive impairment.[59]

Patient activation. Although not specific to alcohol and SUDs, recent research has found that increased levels of patient activation are associated with greater likelihood of treatment initiation and engagement for a range of chronic health conditions.[60, 61, 62] Greene and Hibbard defined patient activation as "having the knowledge, skills, and confidence to manage one's own health."[61, 62] In examining factors related to patient and family activation and accountable care organization (ACO) support for and investment in facilitation of such activation, Shortell et al. (p. 580)[63] found "high-level leadership commitment, goal-setting supported by adequate resources, extensive provider training, use of interdisciplinary care teams, and frequent monitoring and reporting on progress" to be associated with greater patient activation.

2. Provider Factors

Provider attitudes, access and availability, ease of use, referral source, and the type and efficacy of treatment provided affect an individual's initiation and engagement into SUD treatment. Research published in the past 5 years confirms and elaborates on these five overarching themes.

Provider attitudes. Just as stigma can negatively affect individuals' propensity to seek treatment, provider attitudes toward those with SUDs may interfere with willingness to work with that population.[16]

Provider access and availability. Lack of provider availability is routinely cited as a barrier to patients engaging in treatment.[17, 18, 19] Provider-related financial concerns, such as issues related to third-party reimbursement[18] and including benefit limits imposed by payers,[64] may reduce the number of providers willing to offer SUD treatment or restrict their ability to offer the full range of treatments that would otherwise be available. As the Mental Health Parity and Addiction Equity Act (MHPAEA) of 2008 is implemented, some of these impediments may be less pronounced as payers increasingly reimburse the provision of behavioral health care at parity with physical health care.

PROVIDER ACCESS
Lack of provider availability is routinely cited as a barrier to patients engaging in treatment, and provider-related financial concerns may reduce the number of providers willing to offer SUD treatment.

The number of providers available to offer treatment, including the number certified to provide MAT for OUDs, is one major factor that also influences access. Another is the number of certified providers who prescribe buprenorphine--one major MAT option for patients with opioid dependence. There has been a continued increase in the number of providers certified to prescribe buprenorphine in recent years, which subsequently has increased patients' access to treatment.[18] A national survey of physicians certified to prescribe buprenorphine[18]revealed that this treatment option is largely prescribed outside of specialty treatment settings, further expanding access to patients. In 2004, 76 percent of buprenorphine-certified physicians were actively providing buprenorphine treatment to opioid-dependent patients. In 2008, the rate grew to 86 percent. A related factor is the number of patients each buprenorphine prescriber may treat, which also affects the availability of treatment. In 2006, certified prescribers treated an average of 18.4 patients with buprenorphine/naloxone. In 2007, a new policy increased the number of patients that providers are eligible to treat, and the average number of patients treated per physician rose to 27.3 that year and to 39 patients per provider in 2008. A 2016 amendment to the federal regulation governing the number of patients and types of providers who may prescribe buprenorphine is expected to alleviate some of the impediments to provider availability and increase the average number of patients per prescriber as well as the number and type of certified prescribers.[65]

Ease of use. Ease of treatment use is important for initiation and engagement. One major barrier is length of time until an appointment or opening is available to a prospective patient. Longer lengths of time between an index appointment and a treatment initiation appointment have been associated with patients' failure to engage in treatment.[7, 66] Other research shows that decreased wait time is associated with improved retention.[67] Treatment in smaller facilities also may contribute to patients' continued engagement, possibly because of the more intimate and less stigmatizing nature of smaller settings.[7]

EVIDENCE-BASED TREATMENTS
Use of several evidence-based practices may be associated with increased engagement in SUD treatment, as suggested in recent research.

Referral source. Referral source may be an important predictor of patients' initiation of SUD treatment. Research indicates that this may be influenced partially by system characteristics and partially by individual characteristics. Results from recent analysis of treatment episode data indicate that, in 2012, only 22.8 percent and 25.8 percent of all outpatient and intensive outpatient (IOP) admissions were self-referred, a larger percentage originated from the criminal justice system (49.4 percent and 43.9 percent), and the remainder were referrals from other sources. Short-term and long-term residential treatment also was largely non-self-referred: short-term (33.2 percent) and long-term (26.6 percent). In contrast, detoxification was most frequently self-referred: free standing residential (55.8 percent), hospital inpatient (74.2 percent), and ambulatory (50.0 percent).[68] Given that detoxification and inpatient settings often are accessed in crisis, the referral source may be identified as the patient (rather than a source such as a health care provider) whereas residential, outpatient, and IOP settings are most easily and commonly accessed by referral. This suggests that lower rates of self-referral for outpatient treatment may be the best indicator of patient motivation, whereas referral sources for other forms of treatment may be more indicative of how the treatment system functions.

Other research finds connections between referral source and treatment that reveal links to both patient characteristics and system functioning. By analyzing admission delays to outpatient methadone treatment, Gryczynski et al.[54] found that individuals who were referred to treatment by a health care provider had lower odds of delayed treatment. In contrast, individuals who were self-referred or referred by the criminal justice system were more likely to experience a delay in initiating treatment. These findings suggest that system design and provider characteristics may be the predominant factor rather than patient motivation. In contrast, race or ethnicity also may play a role in conjunction with referral source. Acevedo et al.[7] found an interaction between referral source and the patient's race in relation to patient initiation in outpatient treatment. Among those receiving referrals from the criminal justice system, Native American individuals were more likely than White individuals to initiate treatment. Native American and Black patients also were more likely to initiate treatment than White patients when receiving a referral from a health care provider.

Use of evidence-based treatments. Several evidence-based practices exist for the treatment of SUDs, with MAT, contingency management, motivational interviewing, cognitive behavioral therapy, and structured individual or family therapies serving as the most prominent treatments.[69] Use of these practices may be associated with increased engagement in SUD treatment. Recent research shows the following:

  • Use of methadone or buprenorphine for treatment of OUDs positively influences treatment retention.[70, 71]

  • Contingency management, a psychosocial therapy offering positive reinforcement such as a voucher or prize for abstinence or treatment participation,[72] is efficacious for maintaining abstinence from alcohol, cocaine, and opioids; for improving SUD treatment attendance; and for enhancing group cohesion and therapeutic alliance in early stages of group therapy.[73, 74]

  • Contingency management combined with other psychosocial therapy interventions such as motivational interviewing[72] or integrated MAT and mental health treatment[75] also is effective. Higher rates of service utilization have been seen for co-located mental health and methadone maintenance programs when contingency management in the form of a monetary reward also is provided.[75] One drawback of contingency management is the potential for unsustainable treatment incentives because of funding restrictions.

  • Motivational interviewing, which may be used to identify patients' personal barriers and readiness for behavior change relative to substance use,[72] is another evidence-based practice that may support initiation and engagement. Motivational interviewing is used in many health care settings, including SUD treatment,[76, 77] and it presents an alternative to directly inquiring about patients' inclination for behavior change. Instead, the intervention uses a four-step process that builds patient trust until the provider can facilitate a patient-developed commitment and action plan for change.[76] This has been shown to help patients with alcohol use disorder reduce their drinking.[78] Motivational interviewing and treatment readiness group sessions, combined with monetary incentives for enrolling in substance use treatment and attending sessions, was associated with higher rates of enrollment in methadone maintenance treatment, re-engagement in treatment following a program discharge, and reporting a greater number of total treatment days and fewer episodes of heroin use.[79]

  • Receiving group therapy during the initial SUD treatment visit is another predictor of continued engagement.[7]

3. Health Plan/Payer Factors

Health plan factors influence initiation and engagement in substance use treatment. For example, health plan policies related to reimbursement, benefit coverage, and types of credentialed providers included in a network all affect the development of an adequate network for plan beneficiaries and overall access to a care continuum. In addition, favorable cost-sharing or alternative payment arrangements such as pay for performance (P4P) and ACO-like models, as well as care management and quality improvement programs, may improve treatment initiation and engagement.

Benefit Design. Health plans historically have imposed coverage restrictions, including treatment limitations and financial requirements that limit the use of SUD treatment services. Limited health plan benefit arrays, including coverage of services or MAT medications, and caps on office visits may hinder substance use delivery care, ultimately impeding initiation and engagement.[21, 22] Although many of these barriers are changing with implementation of the MHPAEA, health plan policies can substantially affect provider access and ultimately patient engagement.

A national survey of private health plans examined how the plans managed specialty behavioral health treatment entry and continuing care in 2010. Prior authorization only was required for entry into outpatient SUD treatment by 4.7 percent of plans, whereas 73.4 percent required prior authorization for continuation of such treatment. Requirements for entry and continuation were more strenuous to obtain partial hospitalization, IOP services, or day treatment, with 94.9 percent requiring prior authorization for entry and 94.5 percent requiring authorization for continued treatment. Residential treatment was the most difficult to access, with 97.2 percent requiring authorization prior to entry and 95.2 percent for ongoing treatment. Prior authorization was based on medical necessity criteria, which were developed most frequently by either the plan or by the American Society of Addiction Medicine (ASAM). Most plans had formal standards to monitor wait times for routine and urgent care, but 30 percent lacked such standards for detoxification services.[23] Given the implementation of parity, it is expected that many of these impediments may have been alleviated.

A study by Grogan et al. (2016) examined state Medicaid plan coverage of the four ASAM levels of care: (1) outpatient services; (2) IOP services; (3) residential inpatient services; and (4) intensive inpatient services. Researchers used results of a survey and environmental scan conducted in 2013 and 2014 to determine that only 13 states and the District of Columbia covered all services included in the four levels of care, whereas 26 states and the District of Columbia provided coverage for at least one service in each of the four levels. The most common restriction in other states was residential treatment, with 21 states providing no residential treatment. Ten states did not cover IOP services. Only half of the states and the District of Columbia provided funding for recovery support services.[24]

COVERAGE RESTRICTIONS
Health plan coverage restrictions, including treatment limitations and financial requirements that limit the use of SUD treatment services may hinder substance use delivery care, ultimately impeding initiation and engagement.

A 2014 HHS Substance Abuse and Mental Health Services Administration (SAMHSA) report on Medicaid financing of MAT found considerable differences between the states in the state Medicaid reimbursement and benefit limits for MAT. Common benefit design elements that influence access to MAT for both alcohol and OUDs include use of preferred drug status for selected drugs; requirements for prior authorization, step therapy, or psychosocial treatment; and quantity or lifetime limits.[25]

Payment models. Several studies have focused on the use of performance-based payment for SUD counselors. Among therapists treating adolescents for SUDs in a community-based treatment organization, the providers receiving US $50 for each month that they demonstrated competence in substance abuse treatment delivery and US $200 for each patient who received a specified number of treatment procedures and sessions were more likely than the control group to achieve the target rates of treatment procedures. Additionally, the adolescents in the study were more likely to initiate treatment, although there was no significant difference in patient remission status.[66, 80] Where counselors at a community drug treatment clinic could earn cash bonuses based on therapy attendance rates of individual clients as well as on the quarterly retention rates of their caseload, average therapy sessions attended during the first month of treatment increased from 4.6 sessions prior to the intervention to 5.5 sessions per client during the intervention. The 90-day client retention rate increased from 40 percent to 53 percent.[81]

Some state substance use agencies have employed contracts with specialty substance use provider organizations that tie payment to performance across various metrics. One well-studied example is Delaware, which, in 2002, replaced traditional cost-reimbursement contracts with performance-based contracting. The state tracked capacity utilization and active patient participation in treatment to increase the number of people enrolling in and utilizing detoxification services in the state. From 2001 to 2006, the average occupancy rate increased at substance abuse facilities from 54 percent to 95 percent. Some of the more successful strategies to increase occupancy rates were extending hours of operation, enhancing the facility, providing salary incentives to clinicians and utilizing evidence-based therapies.[82] Subsequent studies found that rates of transition to continuing care treatment improved following implementation of performance-based contracting,[81]and that waiting time declined by 13 days whereas treatment length of stay increased.[83]

PAYMENT TIED TO PERFORMANCE: DELAWARE EXAMPLE
In 2002, Delaware replaced traditional cost-reimbursement contracts with performance-based contracting, and saw an average occupancy rate at substance abuse facilities increase from 54% to 95% from 2001 to 2006.

Studies also have examined the effect of using an ACO-like payment structure on SUD treatment. A qualitative study on the early effects of Medicare ACOs on behavioral health processes found that Medicare ACOs were minimally focused on improving processes to connect beneficiaries to SUD services; reasons cited included a perceived lack of referral resources and a lack of provider training within the organization.[84] Researchers also examined the effect of the Blue Cross Blue Shield of Massachusetts Alternative Quality Contract (BCBSMA AQC) on SUD performance measures of identification, initiation, and engagement. The BCBSMA AQC incentivizes provider organizations to control the total cost of care while improving quality measures, but they did not include any measures related to SUD in their quality measure set to which incentives attached. The researchers found that the BCBSMA AQC payment structure had no impact on SUD performance measures.[85]

A study that did not directly focus on substance use treatment identified some impediments to successful use of P4P, at least in certain contexts. A P4P compensation model that strongly incentivized primary care physician (PCP) quality outcomes resulted in PCP frustration at patient behavior, rather than stimulating greater support for patient self-management and activation. However, younger providers and those who were already more patient-centric were least likely to express this frustration.[86] This suggests that organizational strategies to support patient and family activation may be important to supplement the use of P4P,[63] as well as strategies to support and educate providers.

4. Market, Contextual, and Environmental Factors

Market, contextual, and environmental factors either may contribute to or detract from access to SUD treatment. Examples of such factors that influence SUD treatment initiation and engagement may include geography, national policies, and state policies.

Geography and regional variation. Research has shown considerable geographic variation in treatment availability for SUD treatment generally, often locating treatment gaps in the South, Southwest, or Midwest. Results show gaps in availability of providers who accept Medicaid or who are licensed to provide buprenorphine for OUD,[87] as well as limited public treatment services in areas with a high density of African-Americans.[88] A recent study examined geographic variation in OUD treatment need and admissions to opioid treatment programs (OTPs) accepting Medicaid. Of 1,151 of OTPs included in the study, only 65 percent accepted Medicaid. Most counties had no access to OUD treatment in OTPs for Medicaid enrollees, with the greatest gaps in coverage found in the Great Plains and parts of the Southeast. The highest rates of OUD, however, were found in counties in New England, Appalachia and some adjacent areas, and Western states. The analysis found clusters of counties with higher-than-average rates of OUD and lower-than-average treatment admissions to OTPs accepting Medicaid in the Southeast portion of the United States.[87] Fifty-three percent of counties in the United States do not have a physician with the waiver needed to prescribe buprenorphine.[89]

National and state policies. National policies can either restrict or improve individuals' access to health care services, especially regarding patients who are publicly insured. As the largest funder of SUD services,[90, 91] Medicaid plays an important role in facilitating access to specific treatment modalities. Medicaid policies that promote the use of MAT are critical to patients with OUD for their ability to engage in treatment.[92] Such policies include providing coverage for all forms of MAT, including naltrexone, buprenorphine, and methadone for OUD treatment.[92] An analysis of evolving state Medicaid policies between 2004 and 2013 found that many states implemented changes, including adding buprenorphine to preferred drug lists or adding MAT as a covered benefit, thereby promoting access to patient engagement in SUD treatment.[92]

National waiver programs also can be instrumental in increasing access to SUD treatment providers. In 2002, the HHS Food and Drug Administration approved buprenorphine for prescription by providers who received a waiver from the Drug Enforcement Administration (DEA). Providers obtain this waiver after completing educational requirements specific to buprenorphine prescribing practices. Prior to the waiver, approximately 98.9 percent of United States counties were experiencing a shortage of opioid treatment providers.[19] By 2011, 9 years after the waiver program went into effect, the percentage of counties experiencing shortages decreased to 46.8 percent. In 2011, only 10.4 percent of the United States population resided in counties that were classified as having an opioid treatment shortage.[19] The 2016 statutory and regulatory changes regarding types of providers that may become waivered and the number of patients they can serve is anticipated to further improve access to treatment.

Single policy changes alone, however, may be insufficient to improve patient initiation and engagement in treatment. In 2007, Massachusetts implemented a statewide universal insurance law, incorporating SUD services as essential health benefits available to all state residents. An assessment of the law's effect on service uptake revealed that the rate of treatment initiation generally was similar to the rate observed prior to the law, and the need for SUD treatment remained relatively high.[93] Qualitative interviews with community-based SUD treatment organizations revealed that, although coverage had been expanded, patients experienced barriers to processing their insurance applications. Because the state no longer allowed citizens to benefit from acute or emergency service coverage under Medicaid's presumptive eligibility status, patients often could not access timely care for their SUD needs. Additionally, co-payments continued to represent a significant barrier to patients' treatment initiation and continued use of services.[93]

In 2010, the Patient Protection and Affordable Care Act (Affordable Care Act) expanded both public and private insurance coverage, providing greater access to health care. With regard to SUD treatment, the Affordable Care Act eliminated lifetime caps on treatment services and restricted the annual caps that insurance plans can impose.[94] Reducing these insurance-related barriers to treatment may affect the number of individuals initiating and continuing to engage in SUD services, although lack of treatment resources in certain areas, as well as non-expansion of Medicaid in certain states, may continue to impede access to those services.[95]

AFFORDABLE CARE ACT
The 2010 Affordable Care Act eliminated lifetime caps on SUD treatment services and restricted the annual caps that insurance plans can impose.

Reducing these insurance-related barriers may affect the number of individuals initiating and continuing to engage in SUD services.

Additionally, the Affordable Care Act allows young adults aged 19-25 years to remain under their parents' insurance coverage. Initial assessments of the effect of the legislation on young adults' use of substance use services failed to reveal any significant change in treatment uptake.[96] However, given the relatively high rates of substance abuse for this age group,[1] expanded coverage ultimately may promote increased uptake of treatment services.

A study examining the direct effect of the MHPAEA on SUD treatment outcomes found that, after the first year of implementation, no significant change was observed in patient initiation or engagement.[97] However, the direct effects of this law on patient outcomes may be delayed as health plans adjust to and incorporate their new coverage requirements. Health plans also are still in the process of satisfying more recent regulatory requirements,[98] which also will influence implementation.

Initiation and Engagement in Treatment

A basic requirement of successful SUD treatment is that the individual enter treatment and continue to participate long enough to benefit from what the treatment can offer. These steps of entry into treatment and treatment retention are commonly labeled as initiation and engagement. Without initiation and engagement, meaningful treatment does not occur.

Treatment initiation and engagement have been defined in different ways. Treatment initiation generally indicates that a patient has attended at least one treatment or assessment session after being identified as someone who needs treatment for alcohol or drug use disorder or following an admissions process.[7, 11] Treatment engagement implies continued treatment through additional visits, usually a specified number of encounters occurring within a set time period, which may vary depending on the study definition. Engagement also may be examined under the rubric of retention or completion. Presently, the most commonly used definitions are derived from the IET performance measure, which sets a minimum floor for initiation and engagement. We discuss the IET measure definitions in detail in the Methods section of this report, but the simple definitions are as follows:

  • Initiation: the percentage of members who initiate treatment through an inpatient alcohol and other drug (AOD) admission, outpatient visit, IOP encounter, or partial hospitalization within 14 days of diagnosis.[99]

  • Engagement: the percentage of members with a diagnosis of AOD dependence who initiated treatment and had two or more additional services within 30 days of the initiation visit.[99]

Initiation and Engagement Measures

TREATMENT INITIATION
Indicates that a patient has attended at least one treatment or assessment session after being identified as someone who needs treatment for alcohol or drug use disorder or following an admissions process.

According to the National Quality Forum, performance measures "serve as a critically important foundation for initiatives to enhance healthcare value, make patient care safer, and achieve better outcomes."[100] At this point, there are hundreds of performance measures, but the most prominent measure related to SUD treatment is the IET measure.

TREATMENT ENGAGEMENT
Implies continued treatment through additional visits, usually a specified number of encounters occurring within a set time period.

The Healthcare Effectiveness Data and Information Set Measure of Initiation and Engagement

1. IET Measure Development and Adoption

The IET measure was developed by the Washington Circle group in partnership with SAMHSA and the National Committee for Quality Assurance (NCQA) and was designed to be calculated using administrative claims data.[101, 102] In 2004, NCQA included the IET measure in their Healthcare Effectiveness Data and Information Set (HEDIS) quality measures.[101, 102] The HEDIS is the most commonly used set of quality measures in the United States managed health care industry; over 75 percent of United States health plans use them to measure performance.[103] The IET measure is part of both the HEDIS Health Plan measures and the HEDIS Physician Plan measures.[104] In addition to use in the HEDIS measures, HHS uses the IET measure in many quality reporting programs, including the following:

  • HHS Centers for Medicare & Medicaid Services (CMS) Adult Core Set of Health Care Quality Measures for Medicaid (Adult Core Set).

  • Medicare and Medicaid Meaningful Use (MU) Electronic Health Records (EHR) for Eligible Professionals and the MU Stage 2 clinical quality measures, which now are part of the Merit-based Incentive Payment System (MIPS).

  • CMS Medicare Physician Quality Reporting System, which is now part of the MIPS.

  • Physician Feedback/Quality and Resource Use Reports.

  • Physician Value-Based Payment Modifier.

  • Health Insurance Marketplace Quality Initiatives Quality Rating System and Qualified Health Plan Enrollee Experience Survey.

  • CMS Medicare Part C/Medicare Advantage (Part C Star Rating and/or Medicare Part C Display).

  • CMS Medicare and Medicaid Financial Alignment Demonstrations.

  • CMS Medicaid Health Homes.

  • CMS Medicaid Innovative Accelerator Program.

  • CMS Medicaid 1115 Waver on Institutions for Mental Disease (IMD).

  • SAMHSA and CMS Behavioral Health Clinic (BHC) Quality Measures in use as part of the Section 223 Demonstration Program for Certified Community BHCs.[104, 105, 106, 107, 108]

In addition, the IET measure is used by at least four state Medicaid programs to tie Medicaid reimbursements to health plan performance within state Medicaid ACOs. Those states are Maine, New Jersey, Vermont, and Oregon.[109, 110, 111] The IET measure was endorsed by the National Quality Forum in 2009 as measure number 0004.[104]

2. IET Measure Validity

Measure validity is critical if one is to draw conclusions from measure rates. Harris and colleagues have performed a series of studies to assess the validity of the IET measure, including assessing whether the codes used in calculation correspond to the receipt of substance use treatment.[112, 113] Harris et al.[114] and Garnick, Dunigan, and their colleagues also have examined the relationship of the measure to outcomes.[115, 116, 117]

Studies of the relationship of IET codes to receipt of treatment originated in and used data from the Veterans Health Administration (VHA) National Patient Care Database. They assessed whether there was agreement between the code combinations and clinical progress notes regarding treatment. The first such study concluded that VHA SUD specialty facilities had high concordance with clinical progress notes (92 percent to 98 percent accuracy), whereas outside outpatient clinics had a concordance rate of 63 percent and non-SUD specialty inpatient units had a concordance rate of only 46 percent. The researchers concluded that, outside of SUD specialty clinics that were integrated into the VHA, patients may be counted as meeting the HEDIS measures even though they may not have received addiction treatment.[112] A follow-up study found the results in VHA SUD specialty clinics virtually unchanged (90 percent to 96 percent) accuracy. However, non-SUD outpatient and non-SUD inpatient clinics improved to 77 percent and 65 percent concordance with documentation of clinical progress notes, respectively.[113]

Studies also show that IET rates correspond with some patient outcomes but not others. Harris and colleagues[114] found that individuals meeting the HEDIS engagement criterion had statistically significant improvements on the Addition Severity Index alcohol, drug, and legal composite scores, although the improvements were not clinically significant. Garnick and colleagues[116] found that engagement in publicly funded outpatient treatment services was associated with decreased risk of subsequent arrests. Dunigan and colleagues[117] examined the relationship between treatment engagement on employment using multiple outcomes of employment (i.e., any employment, wages, number of quarters employed, and hours worked).

Although they did not find a relationship between engagement and employment in the overall sample, they did find a relationship between engagement and employment and higher wages for those individuals with a history of criminal justice involvement. Similarly, Garnick et al.[115] found improved performance on multiple substance use outcomes among adolescents who engaged in treatment.

NCQA QUALITY COMPASS DATA
Analysis of these data indicates that rates of initiation are higher than rates of engagement across all commercial, Medicaid, and Medicare plans.

3. Structure of the Measure, Including Non-inclusion of MAT

The process for calculating the IET measure rates is explained in detail in the Methods section of this report, as the initiation and engagement rates are dependent variables in quantitative analyses undertaken as part of this study. Performance measures, however, are updated often, most typically with minor revisions to codes used for calculation. Changes to the HEDIS version of the IET measure for 2018 included more substantive changes, such as one addressing the former non-inclusion of MAT in the calculation of receipt of substance use treatment as part of the measure numerator.[118] MAT is now a major part of SUD treatment for alcohol and OUDs, and the amendment addresses that fact, recognizing that initiation or engagement in treatment may include receipt of MAT. Other key changes for 2018 include the addition of services received by telehealth, stratification by age and diagnosis, and extension of the time measured to satisfy the engagement measure from 30 to 34 days. Many of these changes reflect the evolving nature of SUD treatment.

Health Plan Trends for the IET Measure

Since inclusion of IET in the HEDIS measures in 2004, considerable data have been generated that provide information on rates of initiation and engagement. Analysis of NCQA Quality Compass data indicates that rates of initiation are higher than rates of engagement across all commercial, Medicaid, and Medicare plans. Medicare initiation rates generally have been higher than either commercial or Medicaid rates and, for Medicare, Medicaid, and commercial insurance, rates for both measures tend to be lower for health maintenance organization (HMO) plans compared with preferred provider organization (PPO) plans.

Commercial HMO and PPO plans. Figure 2 displays the initiation and engagement trends for commercial HMO and PPO plans from 2005 through 2014. Initiation rates are slightly higher for commercial PPO plans than for commercial HMO plans. However, rates for both have steadily decreased over the last decade. In 2005, 45.8 percent of commercial PPO plan members and 44.5 percent of commercial HMO plan members needing alcohol or drug services initiated treatment. In 2014, the percentages of commercial PPO and HMO plan members initiating treatment dropped nearly 10 percent for both categories to 36.1 percent and 34.7 percent, respectively. Rates of engagement, although much lower than rates of initiation, have remained stable across commercial PPO and HMO plans over the last decade. The mean rate of engagement for PPO plans is 15.4 percent, and the mean rate for HMO plans is 14.6 percent.

FIGURE 2. IET for Commercial HMO and PPO Plans, 2005-2014
FIGURE 2, Line Graph: Displays the initiation and engagement trends for commercial HMO and PPO plans from 2005 through 2014.  Initiation rates are slightly higher for commercial PPO plans than for commercial HMO plans.  However, rates for both have steadily decreased over the last decade.  In 2005, 45.8% of commercial PPO plan members and 44.5% of commercial HMO plan members needing alcohol or drug services initiated treatment.  In 2014, the percentages of commercial PPO and HMO plan members initiating treatment dropped nearly 10% for both categories to 36.1% and 34.7%, respectively.  Rates of engagement, although much lower than rates of initiation, have remained stable across commercial PPO and HMO plans over the last decade.  The mean rate of engagement for PPO plans is 15.4%, and the mean rate for HMO plans is 14.6%.
SOURCE: Author summary of findings from NCQA Quality Compass data.[119]

Medicaid HMO plans. Figure 3 demonstrates the rates of initiation and engagement for Medicaid HMO plans from 2005 through 2014. Both initiation and engagement rates were highest in 2007 at 45.6 percent and 14.4 percent, respectively. Since then, rates for both measures have decreased. The last 3 measured years represent the lowest initiation rates recorded, as well as 3 consecutive years of lower-than-average engagement rates for Medicaid HMO plans.

FIGURE 3. IET for Medicaid HMO Plans, 2005-2014
FIGURE 3, Line Graph:  Demonstrates the rates of initiation and engagement for Medicaid HMO plans from 2005 through 2014.  Both initiation and engagement rates were highest in 2007 at 45.6% and 14.4%, respectively.  Since then, rates for both measures have decreased.  The last 3 measured years represent the lowest initiation rates recorded, as well as 3 consecutive years of lower-than-average engagement rates for Medicaid HMO plans.
SOURCE: Author summary of findings from NCQA Quality Compass data.[119]

Medicare HMO and PPO plans. The average initiation rates for Medicare plans are higher than rates for plans under either commercial or Medicaid insurance (Figure 4). Across the last 10 years, Medicare HMO plans have averaged around a 43.4 percent initiation rate, compared with 41.6 percent in Medicaid and 41.1 percent in commercial HMO plans. The average initiation rate for Medicare PPO plans is even higher (48.6 percent), compared with the commercial PPO plan average (42.4 percent). As with Medicaid, Medicare plans experienced the highest rate of initiation in 2007, with 50.4 percent in HMO plans and 56.5 percent in PPO plans. While HMO plans have seen a steady decrease in initiation rates over time, initiation rates for Medicare PPO dropped in 2008 before spiking in 2009 and 2010; however, Medicare PPO rates have decreased substantially since 2010. In 2014, only 35.1 percent of those needing treatment initiated care in Medicare PPO plans and only 32.5 percent initiated care in Medicare HMO plans. Rates of engagement also decreased over time. Between 2006 and 2008, Medicare PPO engagement rates were higher than those associated with Medicare HMO plans. Since 2009, rates of engagement have remained similar and stable between both plan types. In 2014, 3.3 percent of those needing treatment engaged in care with a Medicare HMO plan, and 3.5 percent engaged in services with a Medicare PPO plan.

FIGURE 4. IET for Medicare HMO and PPO Plans, 2005-2014
FIGURE 4, Line Graph: The average initiation rates for Medicare plans are higher than rates for plans under either commercial or Medicaid insurance.  Across the last 10 years, Medicare HMO plans have averaged around a 43.4% initiation rate, compared with 41.6% in Medicaid and 41.1% in commercial HMO plans.  The average initiation rate for Medicare PPO plans is even higher (48.6%), compared with the commercial PPO plan average (42.4%).  As with Medicaid, Medicare plans experienced the highest rate of initiation in 2007, with 50.4% in HMO plans and 56.5% in PPO plans.  While HMO plans have seen a steady decrease in initiation rates over time, initiation rates for Medicare PPO dropped in 2008 before spiking in 2009 and 2010; however, Medicare PPO rates have decreased substantially since 2010.  In 2014, only 35.1% of those needing treatment initiated care in Medicare PPO plans and only 32.5% initiated care in Medicare HMO plans.  Rates of engagement also decreased over time.  Between 2006 and 2008, Medicare PPO engagement rates were higher than those associated with Medicare HMO plans.  Since 2009, rates of engagement have remained similar and stable between both plan types.  In 2014, 3.3% of those needing treatment engaged in care with a Medicare HMO plan, and 3.5% engaged in services with a Medicare PPO plan.
SOURCE: Author summary of findings from NCQA Quality Compass data.[119]

Interventions Designed to Improve Initiation and Engagement

Several best practices and intervention components for treating SUDs have been developed to address some of the barriers to initiation and engagement. One type of intervention that is discussed in the section above is the implementation of evidence-based clinical practices. Many of these practices have been shown to enhance treatment retention, and efforts to incorporate their implementation in facilities could be expected to increase initiation and engagement rates. There is not, however, complete consensus within the addiction specialist community as to which practices truly meet "best practice" standards.[120]

In the section below, we discuss two other categories of interventions identified in the literature: (1) interventions that have been studied to address special populations; and (2) organizational interventions.

Interventions to Address Special Populations

Recent research has examined factors that are important in targeting SUD interventions for young adults, ethnic minorities, and individuals with co-occurring psychiatric illness. Many of these interventions focus on increasing the "fit" of the treatment with the targeted demographic as well as increasing availability and access to treatment through enhanced contact or coordination.

Young adults. Young adults may respond to treatment differently than older individuals, and age-specific approaches may enhance initiation and engagement. Examples include whether they thrive and remain in treatment better when they are with individuals of similar age and whether they may be more likely to engage in treatment if a harm reduction model is employed.

Results are mixed on whether young adults do better when in treatment with people of similar ages. For example, younger adults face age-related challenges in engaging with other 12-step members.[121] Only 15 percent of Alcoholics Anonymous or Narcotics Anonymous 12-step members are younger than 30 years. Additionally, younger adults may find it difficult to identify other similarly aged individuals who are engaging in sobriety.[121, 122] Thus, it may be challenging for younger adults seeking treatment to engage with the majority of members in these programs.[122, 123] Labbe et al.[123]examined 12-step meeting attendance among adults aged 18-25 years and found that the age composition of participants in meetings significantly moderated the effect of attendance on abstinence. The study results suggested that linking younger adults who were prone to non-adherence to meetings attended by similarly aged peers may improve treatment during the early phases of recovery. However, the results also suggested that continued attendance in meetings with peers of the same age group may be detrimental to encouraging long-term engagement. Research also shows that young adults prefer to reduce their intensity of substance use rather than to fully abstain from use.[124]

Ethnic minorities. Culturally relevant care also plays a major role in patient engagement. A qualitative study examining barriers and facilitators to SUD treatment engagement for American Indian and Alaska Native populations revealed that many providers employ a diverse array of health practices and culture-based interventions to deliver substance abuse treatment services.[125] SUD program directors and Single State Authority (SSA) representatives explained that incorporating traditional interventions created a supportive treatment environment for culturally diverse patients. Additionally, providers found that respecting cultural taboos, including not documenting healing practices, was useful to engaging Alaska Natives and American Indians in SUD treatment. To facilitate this culturally competent care delivery system, several providers and Single State Authorities reported conducting educational trainings with staff as a way to improve knowledge and use of the cultural interventions.[125]

Co-occurring substance use and mental disorders. Individuals with co-occurring substance use and mental disorders have a high-risk for treatment non-adherence and dropout.[26, 126] Specialized interventions may aid in increasing this population's initiation and continued engagement in care. For example, psychosocial interventions delivered through brief in-person sessions and follow-up calls with the patient, as well as through another family member, were shown to improve treatment adherence for individuals with bipolar disorder and a SUD.[126]

Providers may need to pay special attention to younger adults with co-occurring SUDs and mental disorders. As previously stated, younger adults aged 18-25 years are at the highest risk for SUDs.[1] Recent research also suggests that individuals in this age group with serious mental illness are more likely to engage in substance abuse.[92]

Integrated treatment may be a useful method for treating individuals with co-occurring needs and may encourage improved initiation and engagement. Integrated treatment focuses on providing health care services and monitoring two or more conditions, such as a mental health condition and SUD. Patients with integrated treatment often receive a combination of therapies, including psychotherapy and pharmacotherapy. Integrated treatment also may involve a team of providers including a PCP, psychotherapist, and social worker or case manager to help coordinate the patient's care.[26] In a recent review of empirical studies focused on treatment outcomes for individuals with co-occurring conditions,[26]the authors found that case management is an important component in decreasing clients' needs for inpatient treatment and increasing their time in the community. Kelly and Daley[26]found that care models for patients with co-occurring conditions that emphasized the use of case managers who provided continuous support were associated with: (1) patients staying in the community longer; (2) decreased need for inpatient treatment; and (3) decreased drug use and psychosocial issues.

Organizational Interventions

In this section, we describe interventions implemented largely at the organizational level. First, we summarize the results of two large efforts at improving SUD treatment access and retention. These two initiatives were implemented across multiple states and providers to identify solutions to improve access to care and decrease "no-show" rates. Solutions often were individualized for each provider, but several overarching themes emerged. Themes from the results of these initiatives are summarized in Table 6. Second, we report on studies of enhanced outreach by providers and, third, on transformation to patient-centered service delivery. Fourth, we report on efforts underway that are not yet the subject of study but that reflect systematic approaches that may prove useful to improve SUD treatment access.

Multisite interventions aimed to improve access and engagement. Between 2007 and 2010, 10 states participated in the Strengthening Treatment Access and Retention--State Initiative (STAR-SI) program conducted by SAMHSA.[127] Through this initiative, states developed innovative interventions to decrease the number of individuals who do not show up for SUD treatment in up to 15 of their local outpatient clinics. State-level results then were aggregated to determine which interventions were most effective in increasing linkage to care. As previously discussed, behavioral engagement strategies and reminder calls were efficacious in reducing no-show rates. Additionally, several outpatient clinics conducted organizational-level interventions to improve engagement.[127]

Wait time was identified as a major barrier to appointment adherence. Among the 11 clinics reporting this barrier, the overall rate of patients who did not attend treatment that was attributed to wait time was 41.7 percent. Facilities implemented different organizational interventions to reduce their wait times, including offering walk-in appointments, double-booking appointments, and altering the way visits were scheduled. In one facility, the ability of providers to book their own appointments was replaced with a centralized appointment scheduling system. After implementing such interventions to reduce wait times, the overall no-show rate of patients that could be attributed to this factor was reduced by more than 20 percent.[127]

Delays in the admissions process also were cited as a barrier to patients attending their appointments at STAT-SI facilities.[127] Treatment attrition during the admissions phase is a well-documented barrier to engaging patients in care. In a recent literature review, Loveland and Driscoll[128] found that attrition primarily occurs within the first 24-48 hours following patients' initial request for services and increases in likelihood with each day that a patient waits to begin treatment following their initial request. Linking individuals to care on the same day as their initial service request was significantly associated with increased appointment adherence. Across the five studies they assessed, patients linked to treatment on the same day as their request were 2.5 times more likely to attend their treatment appointments, compared with individuals who waited 3-7 days for an appointment.[128]

Within the STAR-SI study, some facilities opted to redesign their admissions process to reduce wait times between appointments. Most facilities altered their processes by reducing the number of steps required by patients before their first appointment, resulting in an over 20 percent reduction in no-show rates across all STAR-SI treatment centers.[127] Other approaches included increasing clinical capacity, which reduced no-show rates by 24.3 percent in six clinics.[127] Enhancing collaboration with SUD treatment referrers also helped decrease clinics' no-show rates. In some cases, collaboration was enhanced by asking the referrer to offer the client an incentive to attend treatment while, for patients referred through the criminal justice system, they advertised a penalty for not attending the visit. Finally, simply creating a more visually attractive and welcoming treatment environment through décor changes helped improve patients' comfort levels and decrease no-show rates by nearly 6 percent.[127]

The Network for the Improvement of Addiction Treatment (NIATx) initiative presents another national effort to improve SUD treatment initiation and retention in local clinics. The NIATx model of process improvement for behavioral health encourages individual treatment facilities to first conduct an agency walk-through to better understand how patients interact with organizational elements of treatment including reception services, initial screening, assessment, admissions, and treatment planning processes.[129] A change team then is established to further identify barriers to treatment engagement in the current organizational processes and to design and implement interventions in a rapid-cycle testing environment. Continuous monitoring and evaluation of the interventions are conducted to assess improvements and determine where additional resources are needed.[129]

Los Angeles County treatment facilities were included in a phased pilot study of the NIATx model between 2005 and 2008.[129] Each of the SUD agencies identified its own improvement objectives on the basis of agency walk-throughs and a review of baseline patient engagement data. Change leaders implemented a variety of interventions to improve admissions processes and treatment retention and to reduce no-show rates. Interventions included increasing contact with prospective patients prior to admission, conducting same-day assessments to improve efficiency, and reducing the amount of paperwork completed for intake and assessment processes. Treatment facilities aiming to improve appointment adherence attached patient incentives to appointments, began providing physical appointment cards to patients, and conducted satisfaction surveys to continue engaging patients in treatment. Aggregate data suggested an 83 percent reduction in no-show rates related to assessment and intake barriers and a 39 percent increase in 30-day retention during phase one of the pilot study.[129]

Phase two of the study included 12 SUD treatment facilities with similar improvement objectives. Facilities seeking to decrease the waiting time between patients' initial contact to their intake or assessment appointment developed various interventions.[129] For example, they merged preassessment phone interviews into a single interview that was conducted during the patient's first interaction with the facility. Other interventions included increasing assessors' appointment availability, offering walk-in assessment services, and sending case managers to prospective patients' homes to complete assessment paperwork. Following the interventions, the average wait time between appointments was 3.5 days--approximately 2.5 days shorter than the facilities' target.[129]

SUD facilities that aimed to achieve overall decreases in their no-show rates for intake and assessment appointments relied on a combination of organizational and incentivized changes. Interventions included maintaining contact with waitlisted prospective patients through daily check-in calls, providing reminder calls the day before assessments, redesigning intake systems to include more assessment appointment times, adjusting appointment times to help clinicians complete paperwork in a timely manner, and providing bus tokens to incentivize patients to attend the appointments.[129] Another successful tactic involved assignment of patients by the primary counselor to a group schedule at intake and allowing counselors to complete new patient assessments at a later appointment. Aggregate data across all facilities with intake or assessment appointment goals demonstrated a 43.4 percent decrease in no-show rates.[129]

FOCI FOR ORGANIZATIONAL INTERVENTIONS
Interventions focus broadly on improving outreach, reducing wait times for both initial and subsequent appointments, using incentive programs, decreasing the complexity of the initial intake process, and improving the patient's experience.

Substance use treatment facilities seeking to improve 30-day retention in treatment adopted a practice of holding weekly meetings with patients during the first 4 weeks of treatment to assess patient satisfaction with the program and treatment plan.[129] Patients were asked to complete surveys regarding ways to further improve treatment. Facilities also adjusted their set meal, medication, and mail delivery times to better accommodate patients' schedules. The establishment of one-on-one welcome meetings between new patients and staff members from different departments within the treatment facility also promoted retention.[129]

Several themes emerged among these initiatives as foci for organizational interventions (Table 6). Specifically, interventions were focused broadly on improving outreach, reducing wait times for both initial and subsequent appointments, using incentive programs, decreasing the complexity of the initial intake process, and improving the patient's experience.

TABLE 6. Themes for Multisite Improvement Efforts to Enhance Initiation and Engagement
Theme Examples of Organizational Interventions
Enhanced outreach
  • Making outreach calls with appointment reminders
  • Enhancing collaboration with the referral source
  • Increasing contact with patients prior to admission or with those on a waiting list
  • Providing physical appointment cards
Reduction of wait times for intake appointments or between appointments
  • Increasing clinical capacity by hiring additional providers
  • Enhancing collaboration with referral source
  • Conducting same-day assessments or providing walk-in assessments
  • Centralizing appointment scheduling and increasing appointment availability
  • Having counselors assign group schedule at intake
Appointment incentives
  • Advertising penalties for not attending appointments
  • Providing patient incentives for attending appointments, such as bus tokens
Decreasing complexity of intake processes
  • Reducing paperwork for intake and admissions
  • Combining multiple preassessment interviews into 1 interview conducted during patient's initial contact
  • Having case managers make home visits to complete paperwork
  • Altering the length of appointments to allow providers to complete paperwork
  • Allowing providers to take more than 1 appointment to complete assessment paperwork
Improving patient experience
  • Improving decor and environment to make it feel more welcoming
  • Using satisfaction surveys or meetings to assess patient satisfaction
SOURCE: Author summary of reports of results of the STAR-SI[127] and NIATx[129] multisite studies.

Enhanced outreach. Additional research examined the use of mobile phone strategies to decrease non-attendance rates. Patients who fail to attend appointments are more likely to drop out of treatment and experience poor outcomes.[73] Meta-reviews of previous research suggest that appointment reminders sent through text messages to patients' mobile phones improve treatment attendance, compared with individuals receiving no reminders.[130, 131, 132] Text reminders represent an efficient intervention by health service providers to improve treatment initiation and adherence[130] and also may be a cost-effective alternative to traditional reminders through phone calls.[132] Mobile phone-based interventions also can be used to support patients' motivation for behavior change. Spohr et al.[133] found that regularly reminding patients of their short-term life goals resulted in higher likelihood of SUD treatment initiation and appointment adherence. Patients who opted not to receive text message reminders attended 56 percent fewer days of treatment. Additionally, phone calls reminding patients of next-day appointments have been useful in reducing the number of patients who do not arrive for intake and assessment appointments as well as in increasing treatment retention.[73, 129]

Patient-centered service delivery. Patient-centered care is a growing movement in health services, exemplified by the new emphasis on the creation of medical homes and integrated care models. This model, which encourages care coordination as well as shared decision-making and patient-centered care, is vastly different from more common models of addiction care. Specifically, individuals with alcohol use disorders traditionally have been offered standalone, group-based, 12-step programs.[134] Although these programs can be efficacious, they do not offer wraparound services or additional treatment options such as MAT, which may help engage some patients in care.[134]

One aspect of providing patient-centered care is ensuring a high level of coordination between patients' providers. Patients who receive a greater level of coordinated care across their primary and specialty care providers, as demonstrated through jointly developed discharge plans and referral to local resources, remain in care longer than patients who do not receive such coordinated care.[27] Research suggests that the positive association between higher levels of continuity-of-care practices exists for both the general population of individuals seeking SUD treatment and for a subgroup of that population experiencing co-occurring psychiatric disorders.[27]

VERMONT
Vermont initiated the health home "hub and spoke" model in 2013 for individuals with OUDs and mental health conditions. This model uses regional opioid treatment providers as hubs to initiate treatment and incorporates a team of office-based opioid treatment providers to deliver ongoing support.

One model of patient-centered integrated care that is increasingly focused on patients with SUDs is Medicaid health homes. Although the results of these initiatives are not yet available, three states--Vermont, Rhode Island, and Maryland--have initiated Medicaid health homes for individuals with SUDs.[135] Medicaid health homes require six core services: comprehensive care management, care coordination, health promotion, comprehensive transitional care follow-up, individual and family support, and referral to community and social support resources.

Vermont initiated their health home "hub and spoke" model in July 2013 for individuals with OUDs and mental health conditions. This model uses regional opioid treatment providers as hubs to initiate treatment or provide care to complex patients, and it incorporates an enhanced team of office-based opioid treatment providers to deliver ongoing support for less complex patients.[135]

Rhode Island also initiated Medicaid medical homes focused on individuals who receive or qualify to receive MAT[135] and have enhanced the services of their opioid treatment providers to offer the range of services required by a medical home. Finally, Maryland initiated their health homes in October 2013, for beneficiaries with OUDs and a co-occurring mental or physical condition and for individuals with serious and persistent mental illness. Their health homes are based in opioid treatment centers for individuals with SUDs and in either psychiatric rehabilitation programs or mobile treatment providers for individuals with severe and persistent mental illness.[135]

Shared decision-making is another model of patient-centered care that can be useful for individuals with SUDs. When patients engage in shared decision-making with providers, their individual preferences, values, and needs are considered in treatment planning. Shared decision-making between providers and patients also ensures that patients have a better understanding of their medical conditions and are supported throughout the treatment process.[76, 134, 136, 137, 138] When patients are actively involved in health care and self-management decisions, they are more likely to engage in care and adhere to treatment.[136] Patient-centered care models can be used in addiction treatment to improve care coordination across primary and specialty care providers and to ensure that patients have access to all necessary resources to promote their full engagement and retention in care.[139]

Promising practices also have been developed in areas that are not specific to SUD treatment. Care management models that incorporate such practices as frequent face-to-face contact, facilitated exchange of patient information among providers, and patient education and behavioral change techniques such as motivational interviewing, have been shown to decrease inpatient admissions among high-risk Medicaid enrollees with chronic conditions.[140, 141]

Unstudied systematic approaches. Many systematic interventions are underway that have not been the subject of published studies. One such intervention is being promoted by the Healthcare Fraud Prevention Partnership (HFPP), which is a group of health plans, state and federal agencies, and others working to prevent fraud and waste associated with opioid prescribing. Although the focus is fraud and waste, they simultaneously are seeking ways to promote recovery from OUD. Priority actions that fall within this goal are: (1) promoting access to MAT; and (2) encouraging the use of data that can be used for activities such as identifying patients at risk of opioid misuse and OUD and providing intervention. The HFPP recommends use of cross-payer data to facilitate these goals. HFPP also seeks to identify and broadly disseminate effective methods for treating OUD. Although much of the HFPP effort relates to reducing inappropriate prescribing and misuse, the approaches being taken also can be instructive for promoting access to treatment. These include provider education regarding guidelines, continuing medical education credits, and a form of "academic detailing" that uses individual consultation. Patient education also plays a role, with HFPP members engaged in segmenting audiences to deliver information where it is needed and developing resources that fit the audience. A third focus, aimed at getting enrollees into MAT, includes approaches such as educating providers, use of technology such as the SAMHSA mobile app, promoting use of new pharmacological formulations such as implantable buprenorphine, promotion of Screening, Brief Intervention, and Referral to Treatment (SBIRT), and use of telehealth. HFPP also seeks to promote use of data to identify problems with opioid use and target corrective action. Some of the data systems available may be prior authorization systems, claims processing systems, and payer data warehouses. The HFPP is attempting to develop methods for its members to share such data but recognizes that constraints such as privacy may be a barrier. Similar barriers exist that often prevent health plans from accessing Prescription Drug Monitoring Program (PDMP) data. Drug utilization reviews, which presently may result in pharmacy lock-ins, are other potentially useful sources of information.[142]

Another systematic approach was announced by the State of Oregon in 2017. The state plans to create a single point of shared responsibility for behavioral health needs for local communities through a regional governance model. The intention is to have all Oregonians served by a coordinated care model for behavioral health--essentially an expansion and modification of the Coordinated Care Organization model that has been in place since 2013 for Medicaid. The model integrates care across systems, so all organizations in a community that are responsible for behavioral health (e.g., community mental health organizations, hospitals, law enforcement, schools, physical health care) will be part of a governance structure to ensure that local resources are used in the most effective way and that there is coordination of care.[143]

Three health plans in California have developed their own approaches to dealing with opioid misuse. Partnership Health Plan of California, a Medicaid plan, approached prescriber education related to overprescribing through incremental formulary changes. These changes were accompanied by intensive education, including in-person regional meetings, webinars with remote facilitators, promoting local development of prescribing guidelines, academic detailing, technical assistance and support related to conversations with patients that encouraged use of outside authority as the rationale for unpopular changes, outlier review, and pharmacy lock-in. They also provided alternative benefits such as acupuncture and chiropractic care, even though these services are not part of the California State Medicaid plan. Blue Shield of California, a commercial plan, added formulary controls, provided utilization reports to prescribers meeting certain criteria, and offered provider outreach for prescribers with problematic prescribing. They also offered prescriber education, provision of alternative benefits, use of lock-in programs, opioid safety coalitions, and advocacy efforts related to drug disposal. Kaiser Permanente of Southern California launched a safe opioid prescribing initiative for all lines of business that had support from the plan's leadership. It used data to help providers see the scope of the overall problem as well as more specific problems, built collaboration teams, relied on peer pressure and support for clinicians, and invested in clinician education. They also offered formulary management, facilitated use of EHRs to incorporate decision support, endorsed and further developed emergency department and urgent care guidelines, enlisted pharmacists to ensure that they also had responsibility for improving opioid access, developed interspecialty support agreements, and provided patient education and support.[144]