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

03/06/2019

Results of the quantitative and qualitative analyses are presented below. Because this is a mixed methods study in which quantitative results informed the subsequent qualitative analyses, the cross-cutting themes that emerged are elucidated in the Discussion section of this report.

Quantitative Results

We address below the results of analyses related to IET measures for SUD treatment and OUD treatment. Tables referenced below are at the end of the text describing the quantitative results for SUD treatment.

IET Measures for SUDTreatment

Plan characteristics. A total of 321 health plans were included in the portion of the study that examined initiation and engagement in SUD treatment, with a mean beneficiary count of 50,585 (Table 10). The majority (62.3 percent) of the plans were PPOs. Thirty percent of the plans covered residential services for SUD. On average, the number of IOP outpatient or partial hospitalization SUD services provided per beneficiary was 0.005, and the mean number of SUD outpatient services was 0.008. Mean median provider reimbursement for outpatient SUD services was $186.25 per user and for inpatient SUD services was $6529.62 per user. Mean median out-of-pocket costs per user for outpatient services was $54.01, and costs per user for inpatient services was $980.20.

Plan beneficiary characteristics. On average, less than 0.5 percent of beneficiaries in these employer health plans had an identified SUD (Table 10). Approximately 55 percent of beneficiaries were between the ages of 18 and 44 years, and nearly 52 percent were female. Among those with an identified SUD, most (53.85 percent) did not use the emergency department, while 22.36 percent used it once, and 23.79 percent used it two times or more during the study period.

State-level market and environmental characteristics. Mean total state spending on the single state agency (SSA) for substance abuse services and state mental health per 1,000 members of the state population was $16,538.80 (Table 10). On average, the 67 percent of individuals in the states served by the plans identified as non-Hispanic White. Just under 20 percent lived below the poverty line and, on average, 66 percent of individuals in the states had private insurance. The mean past-year state prevalence rate of SUDs was slightly greater than 8 percent, with 7 percent aged 18 years and older receiving SUD treatment per 1,000 individuals in the state population. Just over 40 percent of beneficiaries lived in states where all MAT medications for alcohol and OUDs were covered by Medicaid. Sixty-four percent lived in states that require prescribers or dispensers to access the state PDMP in certain circumstances.

TABLE 10. Characteristics of Employer Health Plans Included in the Analysis of NCQA IET Measures for SUD Treatment (N=321)
Health Plan Characteristics N % Mean
Number of beneficiaries --- --- 50584.60
Plan type
PPO 200.00 62.30 ---
HMO or capitated 60.00 18.70 ---
High deductible 61.00 19.00 ---
Reimbursement
OP-OOPa --- --- 54.01
IP-OOPb --- --- 980.20
OP reimbursementa --- --- 186.25
IP reimbursementb --- --- 6529.62
Benefit design
Residential 95.00 29.60 ---
IOP/PH services --- --- 0.0047
OP services --- --- 0.0075
Beneficiary characteristics
SUD beneficiaries --- --- 0.43
Age 18-44 years --- --- 55.06
Female --- --- 51.81
ED use      
   0 times --- --- 53.85
   1 time --- --- 22.36
   2 or more times --- --- 23.79
Market characteristics
SUD prevalence --- --- 8.38
SUD capacity --- --- 7.34
6 MAT medications --- --- 40.30
Non-Hispanic White --- --- 66.79
Poverty --- --- 19.87
Private insurance --- --- 66.01
PDMP --- --- 63.90
SSA spending --- --- 16358.80
SOURCE: Truven Health MarketScan CCAE data, 2013-2014.
  1. Outpatient services include IOP services and partial hospitalization services in addition to other outpatient services.
  2. Inpatient services include inpatient and residential services.

Initiation variable skewness = -0.0627346; Initiation variable kurtosis = 0.27721992.
Engagement variable skewness = 0.85848228; Engagement variable kurtosis = 0.67542441.

Mean NCQA IET measures by health plan characteristics. The mean SUD treatment initiation rate for the health plans studied was 0.53, and the mean engagement rate was 0.14 (Table 11). Initiation and engagement rates did not differ greatly between plan types, although they tended to be somewhat lower in HMO or capitated plans than in either PPOs or high-deductible plans. Plans covering residential services had a marginally higher rate of initiation but not engagement. Plans that were equal to or above the mean in terms of numbers of IOP or partial hospitalization SUD services (initiation 0.58 vs 0.50; engagement 0.21 vs. 0.11) and SUD outpatient services (initiation 0.57 vs. 0.51; engagement 0.18 vs. 0.12) had higher initiation and engagement rates than plans that were below the mean in the provision of those services. Similarly, those with higher median out-of-pocket costs for SUD outpatient services (initiation 0.55 vs. 0.51; engagement 0.15 vs. 0.14) and higher median provider reimbursement for outpatient SUD services (initiation 0.57 vs. 0.51; engagement 0.18 vs. 0.12) had higher initiation and engagement rates compared with those below the mean in out-of-pocket costs and provider reimbursement for outpatient SUD services. These findings on out-of-pocket cost (initiation 0.52 vs. 0.53; engagement 0.14 vs. 0.15) and reimbursement (initiation 0.52 vs. 0.53; engagement 0.14 vs. 0.15) were reversed for inpatient services.

Mean NCQA IET measures by plan beneficiary characteristics. In health plans with a mean or above mean percentage of beneficiaries with an identified SUD, the mean SUD treatment initiation rate (0.56 vs. 0.51) was higher, as was the mean engagement rate (0.16 vs. 0.13), compared with plans that had fewer of these beneficiaries (Table 11). There were few or no differences in rates related to emergency department use or age, although engagement rates were higher in plans where the percentage of beneficiaries aged 18-44 years was equal to or above the mean (0.15 vs. 0.13). Where the percentage of female beneficiaries was equal to or above the mean, rates of both initiation and engagement were lower (initiation 0.51 vs. 0.54; engagement 0.12 vs. 0.16).

TABLE 11. Mean NCQA IET Measures for SUD Treatment by Employer Health Plan Characteristics (N=321)
Health Plan Characteristics Initiation Rate Mean Rate Engagement Rate Mean Rate
Measure rate 0.53 0.14
Plan type
PPO 0.53 0.14
HMO or capitated 0.51 0.14
High deductible 0.52 0.14
Reimbursement
OP-OOPa    
   Plans equal to or above mean 0.55 0.15
   Plans below mean 0.51 0.14
IP-OOPb    
   Plans equal to or above mean 0.52 0.14
   Plans below mean 0.53 0.15
OP reimbursementa    
   Plans equal to or above mean 0.57 0.18
   Plans below mean 0.51 0.12
IP reimbursementb    
   Plans equal to or above mean 0.52 0.14
   Plans below mean 0.53 0.15
Benefit design
Residential 0.54 0.14
IOP/PH services    
   Plans equal to or above mean 0.58 0.21
   Plans below mean 0.50 0.11
OP services    
   Plans equal to or above mean 0.57 0.18
   Plans below mean 0.51 0.12
Beneficiary characteristics
SUD beneficiaries    
   Plans equal to or above mean 0.56 0.16
   Plans below mean 0.51 0.13
Age 18-44 years    
   Plans equal to or above mean 0.53 0.15
   Plans below mean 0.53 0.13
Female    
   Plans equal to or above mean 0.51 0.12
   Plans below mean 0.54 0.16
ED use >2 times    
   Plans equal to or above mean 0.53 0.14
   Plans below mean 0.52 0.14
Market characteristics
SUD prevalence    
   Plans equal to or above mean 0.51 0.14
   Plans below mean 0.55 0.14
SUD capacity    
   Plans equal to or above mean 0.52 0.14
   Plans below mean 0.53 0.14
Six MAT medications    
   Plans equal to or above mean 0.54 0.14
   Plans below mean 0.52 0.14
Non-Hispanic White    
   Plans equal to or above mean 0.54 0.16
   Plans below mean 0.51 0.13
Poverty    
   Plans equal to or above mean 0.53 0.14
   Plans below mean 0.53 0.15
Private insurance    
   Plans equal to or above mean 0.55 0.16
   Plans below mean 0.50 0.13
PDMP    
   Plans equal to or above mean 0.53 0.15
   Plans below mean 0.53 0.13
SSA spending    
   Plans equal to or above mean 0.52 0.14
   Plans below mean 0.53 0.15
SOURCE: Truven Health MarketScan CCAE data, 2013-2014.
  1. Outpatient services include IOP services and partial hospitalization services in addition to other outpatient services.
  2. Inpatient services include inpatient and residential services.

Mean NCQA IET measures by state-level market and environmental characteristics. Differences in initiation and engagement rates between plans equal to or above versus below the mean were minimal related to total state spending on the SSA, percentage of the population below the poverty line, and number of beneficiaries 18 years or older receiving SUD treatment relative to the state population (Table 11). However, when the state past-year prevalence of SUDs was equal to or above the mean, initiation rates were lower (0.51 vs. 0.55). In contrast, initiation rates were higher if a plan was in a state where all MAT medications for alcohol and OUDs were covered by Medicaid (0.54 vs. 0.52), a mean or above mean percentage of the population was non-Hispanic White (0.54 vs. 0.51), or a mean or above mean percentage of the population had private insurance (0.55 vs. 0.50). Engagement rates were higher if a plan was in a state where a mean or above mean percentage of the population was non-Hispanic White (0.16 vs. 0.13), a mean or above mean percentage of the population had private insurance (0.16 vs. 0.13), or where prescribers or dispensers were required to access the PDMP in certain circumstances (0.15 vs. 0.13).

Characteristics by performance on the NCQA initiation measure. Health plans were divided into tertiles on the basis of performance on the initiation measure, with mean rates for the lowest tertile at 0.41, for the middle tertile 0.53, and for the highest tertile 0.64 (Table 12). Compared with low performers, middle and high performers tended to be PPOs. Low performers were less apt to cover residential services and provided far fewer SUD IOP, partial hospitalization, or outpatient SUD services than did middle and high performers. The mean number of IOP or partial hospitalization services per beneficiary ranged from 0.0026 for low performers to 0.0075 for high performers, with the mean number of outpatient services ranging from 0.0051 for low performers to 0.0114 for high performers. Similarly, out-of-pocket outpatient costs were higher for high performers ($58.82) compared with low performers ($45.64), as was outpatient reimbursement ($244.87 vs. $161.79). Both inpatient out-of-pocket costs ($856.24 vs. $1055.87) and reimbursement to providers ($6248.28 vs. $7167.33) were far lower for plans that performed in the upper tertile compared with those in the lowest tertile.

Compared with the lowest performing plans, plans that were highest performing on initiation had more beneficiaries identified with SUDs (0.52 percent vs. 0.39 percent) (Table 12). They also had lower percentages of beneficiaries aged 18-44 years (53.33 percent vs. 55.25 percent). The most pronounced market or environmental characteristics that differed between the lowest and highest tertile plans were: (1) mean total state spending on the SSA (higher for low performing plans); (2) mean percentage of individuals in the state who were non-Hispanic White (lower for low performing plans); and (3) mean percentage of individuals in the state with private insurance (lower for low performing plans).

TABLE 12. Employer Health Plan Characteristics by Performance on the NCQA Initiation Measure for SUD Treatment (N=107)
Health Plan Characteristic Lowest Tertile
Performers N/Mean
Lowest Tertile
Performers %
Middle Tertile
Performers N/Mean
Middle Tertile
Performers %
Highest Tertile
Performers N/Mean
Highest Tertile
Performers %
Initiation measure rate 0.41 --- 0.53 --- 0.64 ---
Number of beneficiaries 46811.60 --- 65667.40 --- 39274.70 ---
Plan type
PPO 59.00 55.10 74.00 69.20 67.00 62.60
HMO or capitated 26.00 24.30 12.00 11.20 22.00 20.60
High deductible 22.00 20.60 21.00 19.60 18.00 16.80
Reimbursement
OP-OOPa 45.64 --- 57.56 --- 58.82 ---
IP-OOPb 1055.87 --- 1028.50 --- 856.24 ---
OP reimbursementa 161.79 --- 152.10 --- 244.87 ---
IP reimbursementb 7167.33 --- 6173.26 --- 6248.28 ---
Benefit design
Residential 27.00 25.20 37.00 34.60 31.00 29.00
IOP/PH services 0.0026 --- 0.0039 --- 0.0075 ---
OP services 0.0051 --- 0.0061 --- 0.0114 ---
Beneficiary characteristics
SUD beneficiaries 0.39 --- 0.38 --- 0.52 ---
Age 18-44 years 55.25 --- 56.61 --- 53.33 ---
Female 52.02 --- 51.81 --- 51.59 ---
ED use            
   0 times 54.91 --- 53.33 --- 53.32 ---
   1 time 21.85 --- 22.86 --- 22.36 ---
   2 or more times 23.25 --- 23.81 --- 24.32 ---
Market characteristics
SUD prevalence 8.42 --- 8.37 --- 8.34 ---
SUD capacity 7.46 --- 7.46 --- 7.10 ---
6 MAT medications 43.15 --- 33.92 --- 43.83 ---
Non-Hispanic White 62.90 --- 66.89 --- 70.57 ---
Poverty 19.71 --- 20.06 --- 19.83 ---
Private insurance 65.22 --- 65.58 --- 67.24 ---
PDMP 61.39 --- 67.94 --- 62.36 ---
SSA spending 17307.40 --- 15781.50 --- 15987.50 ---
SOURCE: Truven Health MarketScan CCAE data, 2013-2014.
  1. Outpatient services include IOP services and partial hospitalization services in addition to other outpatient services.
  2. Inpatient services include inpatient and residential services.

Characteristics by performance on the NCQA engagement measure. Health plans also were divided into tertiles on the engagement measure for SUD services, with mean rates for the lowest tertile at 0.05, the middle tertile at 0.13, and the highest tertile at 0.25 (Table 13). The lowest performing plans had the highest mean number of beneficiaries. Middle and high tertile plans were PPOs to a greater extent than were low performing plans. There were no substantial differences in initiation rates depending on the provision of residential SUD services by the plans. The mean number of IOP or partial hospitalization services per beneficiary ranged from 0.0021 for low performers to 0.0083 for high performers, with the mean number of outpatient services ranging from 0.0051 for low performers to 0.0117 for high performers. Differences in reimbursement characteristics were greatest for median provider reimbursement for outpatient SUD services per user (low performing $137.50 vs. high $271.19), for median provider reimbursement for inpatient SUD services per user (low performing $7239.56 vs. high $6268.03), and for median out-of-pocket costs for inpatient SUD services per user (low performing $996.45 vs. high $965.03).

TABLE 13. Employer Health Plan Characteristics by Performance on the NCQA Engagement Measure for SUD Treatment (N=107)
Health Plan Characteristic Lowest Tertile
Performers N/Mean
Lowest Tertile
Performers %
Middle Tertile
Performers N/Mean
Middle Tertile
Performers %
Highest Tertile
Performers N/Mean
Highest Tertile
Performers %
Engagement measure rate 0.05 --- 0.13 --- 0.25 ---
Number of beneficiaries 56568.50 --- 49913.70 --- 45271.50 ---
Plan type
PPO 57.00 53.30 77.00 72.00 66.00 61.70
HMO or capitated 29.00 27.10 11.00 10.30 20.00 18.70
High deductible 21.00 19.60 19.00 17.80 21.00 19.60
Reimbursement
OP-OOPa 50.72 --- 55.57 --- 55.73 ---
IP-OOPb 996.45 --- 979.12 --- 965.03 ---
OP reimbursementa 137.50 --- 150.06 --- 271.19 ---
IP reimbursementb 7239.56 --- 6081.28 --- 6268.03 ---
Benefit design
Residential 31.00 29.00 32.00 29.90 32.00 29.90
IOP/PH services 0.0021 --- 0.0034 --- 0.0083 ---
OP services 0.0051 --- 0.0058 --- 0.0117 ---
Beneficiary characteristics
SUD beneficiaries 0.41 --- 0.41 --- 0.47 ---
Age 18-44 years 54.98 --- 54.38 --- 55.83 ---
Female 52.11 --- 52.70 --- 50.61 ---
ED use            
   0 times 53.84 --- 53.77 --- 53.94 ---
   1 time 22.45 --- 22.66 --- 21.96 ---
   2 or more times 23.71 --- 23.57 --- 24.10 ---
Market characteristics
SUD prevalence 8.42 --- 8.30 --- 8.41 ---
SUD capacity 8.01 --- 6.83 --- 7.19 ---
6 MAT medications 45.83 --- 34.99 --- 40.07 ---
Non-Hispanic White 62.76 --- 67.67 --- 69.94 ---
Poverty 19.88 --- 20.08 --- 19.64 ---
Private insurance 65.16 --- 65.96 --- 66.92 ---
PDMP 60.94 --- 64.39 --- 66.36 ---
SSA spending 17040.60 --- 15534.40 --- 16501.50 ---
SOURCE: Truven Health MarketScan CCAE data, 2013-2014.
  1. Outpatient services include IOP services and partial hospitalization services in addition to other outpatient services.
  2. Inpatient services include inpatient and residential services.

Major differences in beneficiary characteristics were not seen between plans at different levels of performance (Table 13). Compared with middle performing plans, market and environmental characteristics often were more similar between low and high performing plans. However, the highest tertile performers also had higher percentages of beneficiaries living in states requiring prescribers or dispensers to access the PDMP (low performing 60.94 percent vs. high 66.36 percent) and higher percentages of individuals living in states with a higher percentage of non-Hispanic White population (high performing 69.94 percent vs. 62.76 percent).

TABLE 14. Multivariate Regression Results Examining the Effect of Health Plan and Environmental Characteristics on Employer Health Plan Performance on the NCQA IET Measures for SUD Treatment (N=321)
Health Plan Characteristics Initiation Measure Beta Initiation Measure p-value Engagement Measure Beta Engagement Measure p-value
Number of beneficiaries 6.21E-08 0.4523 -4.1E-09 0.9528
Plan type
PPO Reference Reference Reference Reference
HMO or capitated -0.01858 0.2345 -0.00948 0.4723
High deductible -0.00244 0.8674 -0.00386 0.7541
Reimbursement
OP-OOPa 0.000517 0.0007 9.13E-05 0.4774
IP-OOPb -9.8E-06 0.1948 -4.5E-06 0.4846
OP reimbursementa -1.1E-05 0.6301 2.8E-06 0.8869
IP reimbursementb 1.92E-06 0.2331 3.42E-07 0.8014
Benefit design
Residential 0.0101 0.409 0.000302 0.9766
IOP/PH services 2.06408 0.0103 3.82326 <0.0001
OP services 1.45792 0.1467 4.13869 <0.0001
Beneficiary characteristics
SUD beneficiaries 7.43985 0.0573 -12.6598 0.0001
Age 18-44 years -0.01623 0.7253 -0.00937 0.8102
Female -0.07323 0.5486 -0.20293 0.0497
ED use        
   0 times Reference Reference Reference Reference
   1 time 0.14589 0.2275 -0.12134 0.2347
   2 or more times -0.11496 0.192 -0.08526 0.2518
Market characteristics
SUD prevalence -0.00705 0.68 0.00706 0.6247
SUD capacity -0.00071 0.5954 -0.00138 0.2233
Six MAT medications 0.00639 0.763 -0.00641 0.7201
Non-Hispanic White 0.00248 0.0001 0.0017 0.0019
Poverty 0.00178 0.5746 0.000502 0.8514
PDMP -0.02494 0.2341 0.01716 0.3322
SSA spending -1.5E-06 0.172 1.56E-07 0.8691
SOURCE: Truven Health MarketScan CCAE data, 2013-2014
  1. Outpatient services include IOP services and partial hospitalization services in addition to other outpatient services.
  2. Inpatient services include inpatient and residential services.

Initiation measure regression r2: 0.2609.
Engagement measure regression r2: 0.3476.

Results of multivariate analysis on characteristics influencing initiation and engagement. Characteristics significantly associated with higher rates of SUD treatment initiation among employer health plans included providing higher numbers of IOP and partial hospitalization services per beneficiary (β = 2.06408, p = 0.0103), having higher than the mean median out-of-pocket costs for outpatient SUD services per user (β = 0.000517, p = 0.0007), and being in a state with a higher percentage of individuals who were non-Hispanic White (β = 0.00248, p = 0.0001). (Table 14).

Higher rates of SUD treatment engagement were associated with: (1) providing higher numbers of SUD IOP and partial hospitalization services per beneficiary (β = 3.82326, p <0.0001); (2) providing higher numbers of SUD outpatient services per beneficiary (β = 4.13869, p <0.0001); and (3) being in a state with a higher percentage of individuals who were non-Hispanic White (β = 0.0017, p = 0.0019). Higher rates of engagement were negatively associated with having more beneficiaries in the plan with an identified SUD (β = -12.6598, p = 0.0001) and more beneficiaries who are female (β = -0.20293, p = 0.0497).

IET Measures for OUD Treatment

Plan characteristics. A total of 82 health plans were included in the portion of the study that examined initiation and engagement rates for those with identified OUDs, with a mean beneficiary count of 92,521 (Table 15). The majority (66 percent) of the plans were PPOs. Approximately 37 percent of the plans covered residential services. On average, the number of IOP or partial hospitalization SUD services provided per beneficiary was 0.005 and the mean number of SUD outpatient services was 0.009. Among those beneficiaries with identified OUD, 53 percent did not receive MAT, 3 percent received it for 14 days or less, and 44 percent received it for more than 14 days. Mean median provider reimbursement for outpatient SUD services was $181.83 per user, for inpatient SUD services was $5656.22 per user, and for MAT was $2292.98 per user. Mean median out-of-pocket cost per user for outpatient services was $47.51, mean median cost per user for inpatient services was $767.80, and mean median cost per user for MAT medications was $302.26.

Plan beneficiary characteristics. On average, less than 0.29 percent of beneficiaries in these employer health plans had an identified OUD (Table 15). Approximately 54 percent of beneficiaries were between the ages of 18 and 44 years, and nearly 52 percent were female. Among those with an SUD, most (55.6 percent) did not use the emergency department, while 20.7 percent used it once, and 23.7 percent used it two times or more during the study period.

State-level market and environmental characteristics. For this smaller subset of health plans, mean total state spending on the SSA per 1,000 members of the state population was $16,325.90 (Table 15). On average, 68 percent of individuals in the states served by the plans identified as being non-Hispanic White. Just over 20 percent lived below the poverty line and, on average, 66 percent of individuals in the state had private insurance. The mean past-year state prevalence rate of opioid prescriptions was 93.5 per 100 individuals in the state, with 7 percent aged 18 years and older receiving SUD treatment per 1,000 individuals in the state population. Fifty-two percent of beneficiaries lived in states where all three MAT medications for OUD were covered by Medicaid. Sixty-eight percent lived in states that require prescribers or dispensers to access the state PDMP in certain circumstances. There were approximately 144 OTP spaces available for methadone per 100,000 population in the states, and the mean number of buprenorphine prescribers per 100,000 population was eight.

TABLE 15. Characteristics of Employer Health Plans Included in the Analysis of NCQA IET Measures, Limited to OUDs (N=82)
Health Plan Characteristic N % Mean
Number of beneficiaries --- --- 92521.10
Plan type
PPO 54.00 65.90 ---
HMO or capitated 16.00 19.50 ---
High deductible 12.00 14.60 ---
Reimbursement
MAT OOP --- --- 302.26
OP-OOPa --- --- 47.51
IP-OOPb --- --- 767.80
MAT reimbursement --- --- 2292.98
OP reimbursementa --- --- 181.83
IP reimbursementb --- --- 5656.22
Benefit design
MAT use      
   None --- --- 0.53
   14 days or less --- --- 0.03
   >14 days --- --- 0.44
Residential 30.00 36.60 ---
IOP/PH services --- --- 0.0053
OP services --- --- 0.0090
Beneficiary characteristics
OUD beneficiaries --- --- 0.29
Age 18-44 years --- --- 53.90
Female --- --- 51.91
ED use      
   0 times --- --- 55.61
   1 time --- --- 20.65
   2 or more times --- --- 23.74
Market characteristics
Opioid prescriptions --- --- 93.46
SUD capacity --- --- 7.21
OTP capacity --- --- 143.63
Buprenorphine prescribers --- --- 8.26
3 MAT --- --- 52.00
Non-Hispanic White --- --- 68.27
Poverty --- --- 20.33
Private insurance --- --- 66.11
PDMP --- --- 67.95
SSA spending --- --- 16325.90
SOURCE: Truven Health MarketScan CCAE data, 2013-2014.
  1. Outpatient services include IOP services and partial hospitalization services in addition to other outpatient services.
  2. Inpatient services include inpatient and residential services.

Initiation variable skewness = 0.47826139; Initiation variable kurtosis = 0.16101831.Engagement variable skewness = 0.51762313; Engagement variable kurtosis = -0.2974445.

Mean NCQA IET measures by health plan characteristics. The mean initiation rate for OUD treatment for the health plans was 0.55, and the mean engagement rate for OUD treatment was 0.15 (Table 16). Both initiation and engagement rates tended to be higher in PPO plans, particularly compared with high deductible plans (initiation 0.56 vs. 0.51; engagement 0.16 vs. 0.13). Plans covering residential services had a slightly higher rate of initiation (0.57) and engagement (0.16) compared with the mean per plan. Plans that were equal to or above the mean in terms of numbers of IOP or partial hospitalization SUD services (initiation 0.61 vs 0.51; engagement (0.20 vs. 0.13) and SUD outpatient services (initiation 0.60 vs. 0.52; engagement 0.20 vs. 0.13) had higher initiation and engagement rates than plans that were below the mean in the provision of those services. Plans that were above the mean percentage of beneficiaries with OUDs who received MAT in excess of 14 days did not have higher initiation rates compared with plans with a lower percentage of beneficiaries meeting these characteristics who did have higher engagement rates (0.17 vs. 0.13). Compared with plans below the mean in out-of-pocket costs and provider reimbursement for outpatient services, plans with higher median out-of-pocket costs for SUD outpatient services had marginally lower initiation rates but higher engagement rates (initiation 0.54 vs. 0.55; engagement 0.16 vs. 0.15), and plans with higher median provider reimbursement for outpatient SUD services (initiation 0.58 vs. 0.53; engagement 0.19 vs. 0.13) had higher initiation and engagement rates. Health plans with mean or above mean out-of-pocket costs (initiation 0.53 vs. 0.56; engagement 0.14 vs. 0.17) or provider reimbursement (initiation 0.54 vs. 0.55; engagement 0.14 vs. 0.16) for inpatient services had lower rates for both initiation and engagement. Health plans that had mean or above mean pharmacy reimbursement for MAT showed both higher initiation (0.58 vs. 0.52) and engagement (0.16 vs. 0.15) rates compared with those with pharmacy reimbursement below the mean. When median out-of-pocket costs were equal to or above the mean for MAT medications, initiation rates were lower (0.53 vs. 0.56) and engagement rates higher (0.16 vs. 0.15) compared with plans with lower out-of-pocket costs.

TABLE 16. Mean NCQA IET Measures by Employer Health Plan Characteristics, Limited to OUDs (N=41)
Health Plan Characteristic Initiation Rate Mean Rate Engagement Rate Mean Rate
Measure rate 0.55 0.15
Plan type
PPO 0.56 0.16
HMO or capitated 0.53 0.15
High deductible 0.51 0.13
Reimbursement
MAT OOP    
   Plans equal to or above mean 0.53 0.16
   Plans below mean 0.56 0.15
OP-OOPa    
   Plans equal to or above mean 0.54 0.16
   Plans below mean 0.55 0.15
IP-OOPb    
   Plans equal to or above mean 0.53 0.14
   Plans below mean 0.56 0.17
MAT reimbursement    
   Plans equal to or above mean 0.58 0.16
   Plans below mean 0.52 0.15
OP reimbursementa    
   Plans equal to or above mean 0.58 0.19
   Plans below mean 0.53 0.13
Median provider reimbursement for inpatient SUD servicesb    
   Plans equal to or above mean 0.54 0.14
   Plans below mean 0.55 0.16
Benefit design
MAT use >14 days    
   Plans equal to or above mean 0.55 0.17
   Plans below mean 0.55 0.13
Residential services 0.57 0.16
IOP/PH services    
   Plans equal to or above mean 0.61 0.20
   Plans below mean 0.51 0.13
OP services    
   Plans equal to or above mean 0.60 0.20
   Plans below mean 0.52 0.13
Beneficiary characteristics
OUD beneficiaries    
   Plans equal to or above mean 0.58 0.15
   Plans below mean 0.52 0.15
Age 18-44 years    
   Plans equal to or above mean 0.54 0.17
   Plans below mean 0.55 0.14
Female    
   Plans equal to or above mean 0.52 0.12
   Plans below mean 0.57 0.18
ED use 2 times or more    
   Plans equal to or above mean 0.58 0.17
   Plans below mean 0.52 0.13
Market characteristics
Opioid prescriptions    
   Plans equal to or above mean 0.59 0.18
   Plans below mean 0.51 0.13
SUD capacity    
   Plans equal to or above mean 0.51 0.14
   Plans below mean 0.57 0.16
OTP capacity    
   Plans equal to or above mean 0.53 0.14
   Plans below mean 0.56 0.16
Buprenorphine prescribers    
   Plans equal to or above mean 0.55 0.16
   Plans below mean 0.54 0.15
3 MAT medications    
   Plans equal to or above mean 0.59 0.17
   Plans below mean 0.52 0.14
Non-Hispanic White    
   Plans equal to or above mean 0.59 0.18
   Plans below mean 0.52 0.13
Poverty    
   Plans equal to or above mean 0.55 0.15
   Plans below mean 0.54 0.16
Private insurance    
   Plans equal to or above mean 0.59 0.17
   Plans below mean 0.50 0.13
PDMP    
   Plans equal to or above mean 0.52 0.15
   Plans below mean 0.58 0.16
SSA spending    
   Plans equal to or above mean 0.55 0.16
   Plans below mean 0.54 0.14
SOURCE: Truven Health MarketScan CCAE data, 2013-2014.
  1. Outpatient services include IOP services and partial hospitalization services in addition to other outpatient services.
  2. Inpatient services include inpatient and residential services.

Mean NCQA IET measures by plan beneficiary characteristics. In health plans with a mean or above mean percentage of beneficiaries with an identified OUD, the mean initiation rate (0.58 vs. 0.52) was higher compared with plans with fewer beneficiaries with these characteristics, while there were no differences for engagement (Table 16). Both initiation (0.58 vs. 0.52) and engagement (0.17 vs. 0.13) rates were higher in plans with mean to above mean percentages of beneficiaries with OUD who used the emergency department two or more times. Engagement rates were higher in plans where the percentage of beneficiaries aged 18-44 years was equal to or above the mean (0.17 vs. 0.14). Where the percentage of female beneficiaries was equal to or above mean, rates of both initiation and engagement were lower (initiation 0.52 vs. 0.57; engagement 0.12 vs. 0.18).

Mean NCQA IET measures by state-level market and environmental characteristics. Initiation and engagement rates for OUD treatment were somewhat higher for plans in states where total state spending on the SSA was equal to or above the mean (initiation 0.55 vs. 0.54; engagement 0.16 vs. 0.14) and where the number of buprenorphine prescribers per 100,000 state population was equal to or above the mean (initiation 0.55 vs. 0.54; engagement 0.16 vs. 0.15) (Table 16). Both rates were quite a bit higher for plans in states that were equal to or above the mean for prevalence of opioid prescriptions per 100 people (initiation 0.59 vs. 0.51; engagement 0.18 vs. 0.13), states where all three OUD MAT medications were covered by Medicaid (initiation 0.59 vs. 0.52; engagement 0.17 vs. 0.14), where the percentage of the non-Hispanic White population was higher (initiation 0.59 vs. 0.52; engagement 0.18 vs. 0.13), and where more of the population had private insurance (initiation 0.59 vs. 0.50; engagement 0.17 vs. 0.13). Where the number of beneficiaries aged 18 or older receiving SUD treatment per 1,000 population was at or above mean, both initiation and engagement rates were lower (initiation 0.51 vs. 0.57; engagement 0.14 vs. 0.16); the same was true where the number of OTP spaces for methadone was greater (initiation 0.53 vs. 0.56; engagement 0.14 vs. 0.16). Similarly, both initiation and engagement rates were lower if a plan was in a state where prescribers or dispensers were required to access the PDMP in certain circumstances (initiation 0.52 vs. 0.58; engagement 0.15 vs. 0.16).

Characteristics by performance on the NCQA initiation measure. Health plans were divided into low and high performers on the basis of rates of OUD initiation, with mean initiation rates for low performers of 0.50 and for high performers of 0.59 (Table 17). Low performers tended to have a greater number of beneficiaries (118,862 on average), compared with high performers (66,180 on average). High performers were more often PPOs (71 percent) than were low performers (61 percent). Low performers were less apt to cover residential services and provided far fewer SUD IOP, partial hospitalization, or outpatient SUD services than did high performers. The mean number of IOP or partial hospitalization services per beneficiary ranged from 0.0036 for low performers to 0.0071 for high performers, with the mean number of outpatient services ranging from 0.0067 for low performers to 0.0114 for high performers. Higher percentages of those with OUDs received MAT for longer than 14 days (47 percent) compared with low performers (42 percent). Out-of-pocket inpatient costs were lower for high performers ($914.44 vs. $621.15), as was provider reimbursement for inpatient SUD services ($5790.96 vs. $5521.48). Out-of-pocket costs for MAT medications ($301.91 vs. $302.61) and pharmacy reimbursement for MAT medications ($2187.43 vs. 2398.52) also were lower for low performers compared with high performers on the initiation measure. Out-of-pocket outpatient costs were lower for high performers ($45.16) compared with low performers ($49.86), whereas outpatient reimbursement showed higher rates for high performers ($147.78 vs. $215.88).

Compared with the lowest performing plans, plans that were highest performing on initiation had more beneficiaries identified with OUDs (0.33 percent vs. 0.26 percent) (Table 17). They also had higher percentages of beneficiaries between the ages of 18 and 44 years (54.67 percent vs. 53.14 percent) and higher percentages of beneficiaries who used the emergency department two or more times (24.69 vs. 22.79). Higher-performing plans had fewer beneficiaries who were female (50.33 vs. 53.48). Market and environmental characteristics with little distinction between a low and high performing plan included level of poverty in the state, private insurance penetration in the state, and availability of buprenorphine providers in the state, although the latter was somewhat higher for high performing plans (8.55 vs. 7.98). The high performers did have more beneficiaries in states with high prevalence of opioid prescriptions (99.58 vs. 87.33 per 100 population), coverage of all three OUD MAT medications (57.47 percent vs. 46.54 percent), and populations with higher percentages of non-Hispanic White individuals (71.60 percent vs. 64.95 percent). High performing plans had a lower mean number of beneficiaries aged 18 years or older receiving SUD treatment (6.19 vs. 8.23 per 1,000 population), lower numbers of OTP spaces available for methadone (127.54 vs. 159.72, per 100,000 population), less money spent on the state SSA per person ($15,300.00 vs. $17,351.80), and fewer beneficiaries living in states requiring prescribers or dispensers to access the PDMP (61.90 percent vs. 74.00 percent).

TABLE 17. Employer Health Plan Characteristics by Performance on the NCQA Initiation Measure, Limited to OUDs (N=41)
Health Plan Characteristic Low Performers N/Mean Low Performers % High Performers N/Mean High Performers %
Initiation measure rate 0.50 --- 0.59 ---
Number of beneficiaries 118862.00 --- 66180.00 ---
Plan type
PPO 25.00 61.00 29.00 70.70
HMO or capitated 9.00 22.00 7.00 17.10
High deductible 7.00 17.10 5.00 12.20
Reimbursement
MAT OOP 301.91 --- 302.61 ---
OP-OOPa 49.86 --- 45.16 ---
IP-OOPb 914.44 --- 621.15 ---
MAT reimbursement 2187.43 --- 2398.52 ---
OP reimbursementa 147.78 --- 215.88 ---
IP reimbursementb 5790.96 --- 5521.48 ---
Benefit design
MAT use        
   None 56.00 --- 50.00 ---
   14 days or less 2.00 --- 3.00 ---
   >14 days 42.00 --- 47.00 ---
Residential 14.00 34.10 16.00 39.00
IOP/PH services 0.0036 --- 0.0071 ---
OP services 0.0067 --- 0.0114 ---
Beneficiary characteristics
OUD beneficiaries 0.26 --- 0.33 ---
Age 18-44 years 53.14 --- 54.67 ---
Female 53.48 --- 50.33 ---
ED use        
   0 times 57.10 --- 54.12 ---
   1 time 20.10 --- 21.19 ---
   2 or more times 22.79 --- 24.69 ---
Market characteristics
Opioid prescriptions 87.33 --- 99.58 ---
SUD capacity 8.23 --- 6.19 ---
OTP capacity 159.72 --- 127.54 ---
Buprenorphine prescribers 7.98 --- 8.55 ---
3 MAT 46.54 --- 57.47 ---
Non-Hispanic White 64.95 --- 71.60 ---
Poverty 20.32 --- 20.33 ---
Private insurance 65.24 --- 66.99 ---
PDMP 74.00 --- 61.90 ---
SSA spending 17351.80 --- 15300.00 ---
SOURCE: Truven Health MarketScan CCAE data, 2013-2014.
  1. Outpatient services include IOP services and partial hospitalization services in addition to other outpatient services.
  2. Inpatient services include inpatient and residential services.

Characteristics by performance on the NCQA engagement measure. Health plans also were divided into high and low performers on OUD engagement, with mean rates of 0.10 for the low performers and 0.21 for the high performers (Table 18). The lowest performing plans for engagement also had the highest mean number of beneficiaries. Seventy-six percent of high performing plans were PPOs, compared with 56 percent of low performing plans. Residential SUD treatment was provided by a higher percentage of high performing plans (42 percent) compared with low performers (32 percent). The mean number of IOP or partial hospitalization services per beneficiary ranged from 0.0031 for low performers to 0.0075 for high performers, with the mean number of outpatient services ranging from 0.0061 for low performers to 0.0120 for high performers. Compared with low performing plans, high performers were more likely to have beneficiaries with OUD who received MAT for more than 14 days (low performing 41 percent vs. high 48 percent). Differences in reimbursement characteristics were largest for median provider reimbursement for inpatient SUD services per user (low performing $5758.57 vs. high $5553.86), median out-of-pocket costs for inpatient SUD services per user (low performing $890.25 vs. $645.35), and median provider reimbursement for outpatient SUD services per user (low performing $136.31 vs. high performing $227.34). Median outpatient SUD out-of-pocket costs also were higher for high performing plans, but out-of-pocket costs for MAT were lower for high performing plans, as was pharmacy reimbursement for MAT.

TABLE 18. Employer Health Plan Characteristics by Performance on the NCQA Engagement Measure, Limited for OUDs (N=41)
Health Plan Characteristic Low Performers N/Mean Low Performers % High Performers N/Mean High Performers %
Engagement measure 0.10 -- 0.21 --
Number of beneficiaries 115244.00 -- 69797.80 --
Plan type
PPO 23.00 56.10 31.00 75.60
HMO or capitated 10.00 24.40 6.00 14.60
High deductible 8.00 19.50 4.00 9.80
Reimbursement
MAT OOP 304.42 --- 300.10 ---
OP-OOPa 46.30 --- 48.71 ---
IP-OOPb 890.25 --- 645.35 ---
MAT reimbursement 2300.95 --- 2285.01 ---
OP reimbursementa 136.31 --- 227.34 ---
IP reimbursementb 5758.57 --- 5553.86 ---
Benefit design
MAT use        
   None 57.00 --- 49.00 ---
   14 days or less 2.00 --- 3.00 ---
   >14 days 41.00 --- 48.00 ---
Residential 13.00 31.70 17.00 41.50
IOP/PH services 0.0031 --- 0.0075 ---
OP services 0.0061 --- 0.0120 ---
Beneficiary characteristics
OUD beneficiaries 0.27 --- 0.31 ---
Age 18-44 years 52.29 --- 55.52 ---
Female 53.28 --- 50.53 ---
ED use        
   0 times 56.87 --- 54.36 ---
   1 time 20.22 --- 21.08 ---
   2 or more times 22.92 --- 24.57 ---
Market characteristics
Opioid prescriptions 93.29 --- 93.63 ---
SUD capacity 7.88 --- 6.54 ---
OTP capacity 151.28 --- 135.99 ---
Buprenorphine prescribers 7.95 --- 8.58 ---
3 MAT 52.41 --- 51.59 ---
Non-Hispanic White 65.71 --- 70.84 ---
Poverty 20.75 --- 19.90 ---
Private insurance 65.21 --- 67.02 ---
PDMP 69.36 --- 66.54 ---
SSA spending 16110.90 --- 16540.90 ---
SOURCE: Truven Health MarketScan CCAE data, 2013-2014.
  1. Outpatient services include IOP services and partial hospitalization services in addition to other outpatient services.
  2. Inpatient services include inpatient and residential services.

Major differences in beneficiary characteristics were not seen between plans at different levels of performance, although high performing plans had higher percentages of beneficiaries with an identified OUD, had more beneficiaries with OUD using the emergency department two or more times, more beneficiaries between the ages of 18-44 years, and fewer beneficiaries who were female. Examination of market and environmental characteristics revealed that the factors most strongly differentiating low from high performing plans on the engagement measure for OUD treatment were that high performing plans were most often in states that spent more on the SSA per state population (low performing $16,110.90 vs. high $16,540.90), were less likely to be in states where prescribers or dispensers are required to access the PDMP (low performing 69.36 percent vs high 66.54 percent), had fewer OTP spaces for methadone (low performing 151.28 vs. high 135.99 per 100,000 population), had higher numbers of non-Hispanic White individuals in the population (low performing 65.71 percent vs. high 70.84 percent), and had higher numbers of individuals in the state with private insurance (low performing 65.21 percent vs. high 67.02 percent).

Results of multivariate analysis on characteristics influencing initiation and engagement. Characteristics significantly associated with higher rates of initiation of OUD treatment among employer health plans included providing higher numbers of IOP and partial hospitalization services per beneficiary (β = 4.47344, p = 0.0409) and being in a state with above mean prevalence of opioid prescriptions per 100 people in the state (β = 0.00228, p = 0.024) (Table 19). Negative associations also were seen, including higher rates of initiation of OUD treatment negatively associated with being in a state where prescribers or dispensers are required to access the PDMP under certain circumstances (β = -0.0864, p = 0.0362).

TABLE 19. Multivariate Regression Results Examining the Effect of Health Plan and Environmental Characteristics on Employer Health Plan Performance on the NCQA IET Measures, Limited to OUDs (N=82)
Health Plan Characteristics Initiation Measure Beta Initiation Measure p-value Engagement Measure Beta Engagement Measure p-value
Number of beneficiaries 2.16E-08 0.7804 -4.4E-08 0.2267
Plan type
PPO Reference Reference Reference Reference
HMO or capitated 0.01573 0.4804 -0.00602 0.5628
High deductible 0.0022 0.922 -0.01354 0.2006
Reimbursement
MAT OOP -1.5E-06 0.98 1.16E-05 0.6735
OP-OOPa 0.000373 0.1497 0.000139 0.2494
IP-OOPb -1.1E-05 0.4726 -5E-06 0.4841
MAT reimbursement -7.7E-06 0.6506 1.53E-06 0.8475
OP reimbursementa 0.000129 0.1579 8.18E-05 0.057
IP reimbursementb -7.8E-07 0.8422 1.01E-06 0.5826
Benefit design
MAT use        
   None Reference Reference Reference Reference
   14 days or less 0.52499 0.1406 0.22302 0.179
   >14 days 0.05631 0.5172 0.03338 0.4114
Residential 0.00705 0.6487 0.00124 0.8637
IOP/PH services 4.47344 0.0409 4.07017 0.0001
OP services -1.0704 0.5242 -0.57529 0.4635
Beneficiary characteristics
OUD beneficiaries 0.34887 0.9667 -10.549 0.0089
Age 18-44 years -0.04029 0.5353 -0.02013 0.507
Female -0.27617 0.13 -0.1958 0.0233
ED use        
   0 times Reference Reference Reference Reference
   1 time 0.12579 0.5519 0.01033 0.9165
   2 or more times -0.03954 0.7857 -0.0384 0.572
Market characteristics
Opioid prescriptions 0.00228 0.024 -0.00013 0.7705
SUD capacity 0.00013 0.4067 -9.1E-05 0.2132
OTP capacity 0.00567 0.3107 0.00221 0.3977
Buprenorphine prescribers -0.07678 0.0352 -0.03747 0.028
3 MAT 0.000122 0.948 0.000873 0.3197
Non-Hispanic White -0.00541 0.4227 -0.0006 0.8484
PDMP -0.0864 0.0362 0.00574 0.761
SSA spending -8.2E-07 0.8013 1.35E-06 0.3756
SOURCE: Truven Health MarketScan CCAE data, 2013-2014.
  1. Outpatient services include IOP services and partial hospitalization services in addition to other outpatient services.
  2. Inpatient services include inpatient and residential services.

Initiation measure regression r2: 0.6101.
Engagement measure regression r2: 0.6625.

Higher rates of engagement were associated with providing higher numbers of SUD IOP and partial hospitalization services per beneficiary (β = 4.07017, p = 0.0001). Negative associations also were seen, such as higher rates of engagement negatively associated with having a higher percentage of beneficiaries with an identified OUD (β = -10.549, p = 0.0089) or having a higher percentage of beneficiaries who are female (β = -0.1958, p = 0.0233).

Qualitative Results

Plan Characteristics

Six health plans participated in site visit interviews--five Medicaid plans and one commercial plan. The plans served geographically diverse populations across the United States. Two plans served Western states, two plans covered Midwestern states, one served a Northeastern state, and one served a Southeastern state. Health plans described covering diverse populations, including urban and rural populations. They varied substantially in the size of their membership, ranging from approximately 9,880 to 2.9 million covered lives.

Group interviews with health plans included plan representatives in varying roles--from executive leadership to quality improvement strategy teams to clinicians and other staff members engaged in beneficiary outreach efforts. The research team interviewed a total of 65 health plan stakeholders, averaging 11 individuals per plan. To obtain information regarding health plan governance, organization, culture, and strategy from key systems leaders, across all site visits the researchers interviewed two health plan presidents; eight chief executive officers, operating officers, or other individuals in operations leadership positions; four network and contracting leaders; two utilization management leaders; two community relations and product management leaders and staff members; two chief medical officers; two plan medical directors; and six behavioral health medical directors. Quality improvement team members interviewed included 12 quality improvement strategy or corporate quality directors and staff members. In addition to medical personnel employed in the positions referenced above, to obtain information on beneficiary outreach and management and implementation of quality improvement strategies, we interviewed clinical stakeholders, including nine health plan affiliated providers, four case management team members, and nine care coordinator team members.

Interviews with the health plan stakeholders revealed several factors that health plans perceive as influencing their ability to initiate and engage beneficiaries in SUD treatment. Results from the qualitative analyses are grouped by qualitative research question, and brief deidentified summaries of health plan visits are included in Appendix F.

Qualitative Research Question 1: Which types of health plan characteristics and strategies are demonstrated by plans with higher performance or greater improvement in IET in SUD and OUD treatment?

Health plan governance and organizational structure. Interviewees were asked to describe their health plan structure, including leadership organization and governance over behavioral health services and SUD IET strategies. Health plan representatives generally described a multilevel governance approach, including corporate and local oversight of behavioral health care, which included SUD services. National or regional insurance companies operating state Medicaid plans described varying mixtures of centralized, corporate oversight for behavioral health with local execution of procedures and policies regarding behavioral health utilization management, care management, and care coordination strategies. National insurance companies operating with centralized corporate leadership noted that their approach enabled them to streamline decision-making and ensure consistency across their business lines, which included other state Medicaid plans, Medicare, and commercial business lines. However, all of the national and regional insurance companies stressed that some level of local decision-making was critical to implementing behavioral health policies and procedures in ways that respond to local population needs.

The extent of health plans' emphasis on local governance represented a spectrum--from having limited local oversight of policy implementation, to equally shared decision-making with the corporate office, to local leadership acting with authority over the majority of health plan operations and corporate executives viewed as consultants for guidance on specific issues (Figure 9). Regional health plans favoring local governance noted that limits on the plan's corporate decision-making were critical to achieving a managed care model that served local population needs. Representatives of these plans described the importance of ensuring local leadership, with state-specific plan presidents, medical directors, and behavioral health directors overseeing locally stationed case management and care coordination teams.

FIGURE 9. Spectrum of Governance Structures and Factors Affecting Health Plan Organization
FIGURE 9, Diagram: This double arrow diagram represents the spectrum of governance structures, the extent of health plans’ emphasis on local governance represented a spectrum--from having limited local oversight of policy implementation, to equally shared decision-making with the corporate office, to local leadership acting with authority over the majority of health plan operations and corporate executives viewed as consultants for guidance on specific issues.

Similarly, plans that serve smaller beneficiary populations or that were not nationally recognized health insurance brands also favored more local control over decision-making and policy implementation efforts. Leadership from locally governed plans described the importance of a "feet-on-the-street" approach, which was supported by the interviews with care managers and others. As such, representatives from locally governed plans frequently described how their organizational structure promoted regular opportunities for communication about beneficiary needs or health services access challenges among plan presidents, medical directors, and staff members directly involved in beneficiary outreach. Health plan representatives described having integrated weekly and monthly rounds with clinicians and oversight staff members to discuss beneficiaries with complex needs or anecdotally observed trends in initiation and engagement success.

The differences in philosophy and approach between the large national plan with more centralized leadership and the regional or small plans with much more local control do not manifest clearly in the plans' relative rates of initiation or engagement on IET or on other behavioral health measures. The state Medicaid plan operated by the large centralized insurer had one of the highest possible rates on initiation but had an engagement rate that was in the 80th percentile. Plans with pronounced local governance had somewhat similar mixtures or had exceptional results on both rates.

Promoting care coordination models and culture. Interviewees from every health plan described their plan's care model and culture as integral to their success in initiating and engaging beneficiaries in treatment. Care models consistently were described as focused on care coordination. Interviewees emphasized the importance of promoting an understanding of patients' needs for ongoing coordination of physical, mental, behavioral, and substance use-specific services while also managing additional needs such as housing. Having plan-wide care coordination models was described as an actionable way to promote health plans' mission statements and values. Interviewees described their health plan culture--and thus care coordination models--as reflecting a holistic view of member needs, concerned for underserved populations, and focused on collaborative efforts between plan leadership, clinicians, and plan members.

Interviewees commented that their respective health plans sustained and reinforced their care culture and values by tailoring their processes for staff hiring and provider contracting around the plan's mission statements. Most plans described some process for vetting new care coordination staff and clinical providers on the basis of their perceived willingness to approach members' initiation in SUD treatment as a continuous process, rather than an episodic service. Health plan representatives also expressed a desire to hire care managers who were willing to go beyond phone outreach and follow up with members in the community, including conducting house calls, meeting in hospitals or detox facilities, or locating them at community-based recovery support services. Additionally, plan representatives generally described hiring requirements for outreach staff that extended beyond clinical competency and focused on soft skills including communication and demonstrating empathy and patience with members.

Interviewees at high performing plans also described a preference for hiring care managers and care coordinators who were skilled clinicians with master's degrees and a few years of experience in a variety of care coordination roles. Effective care coordinators and outreach workers frequently were described as "trouble shooters" who can identify members' unmet needs. Plan representatives described hiring for a variety of outreach and care coordination roles. Behavioral health and medical care managers frequently are used to conduct face-to-face visits with members, coordinate care plans, and review entitlements. Plans use clinical community specialists and community health workers to conduct community outreach with hard-to-reach members including homeless individuals.

All the health plan representatives described the role of hiring case managers, care coordinators, and community health workers as promoting beneficiaries' use of services included within the plan's benefit array. However, several plans also described these staff members as critical to identifying additional community-based recovery supports for members beyond the plan's covered benefits. Health plans expect these staff members to coordinate external recovery supports in the hope that members would maintain engagement with treatment services longer and become more stable.

Health plan leadership and network contracting staff members described efforts to convey the health plan's mission statement when meeting with new providers. Health plan representatives generally expressed a desire to expand their provider network, but many were concerned about including providers that do not emulate their health plan values. Provider contracting teams described meeting with new providers to reinforce the plans' commitment to continuous engagement with beneficiaries--that repeated successes and failures with SUD treatment initiation are part of the recovery process and providers must continuously engage patients in communication about the benefits of treatment. The goal is to repeatedly reinforce this message so that, if the patient is hearing this on a day when he or she is receptive, the provider will be able to initiate a treatment plan with the patient. Plan representatives described hiring or contracting with providers and staff members who would promote a culture of acceptance among staff and members.

Benefit array. Health plan representatives described significant differences in their benefit arrays. Medicaid plan representatives consistently described coverage of outpatient and inpatient services, but some stated that they do not reimburse for certain of the intermediate services such as partial hospitalization, and only one reimbursed for limited residential care. Half of the Medicaid plan representatives also described the need for prior authorization before members could engage in several types of SUD treatment services. However, none of the Medicaid plans required beneficiaries to pay for any services out-of-pocket. The representative of the commercial plan interviewed for this study described the plan's benefit array as an "all-you-can-eat buffet" of services for beneficiaries, free of prior authorization or utilization management review. Although the plan covers an expansive continuum of SUD treatment services, members are required to meet their plan deductible prior to having all service costs reimbursed by the plan. Deductibles vary on the basis of individual plans offered through the commercial insurer.

SIGNIFICANT DIFFERENCES
Health plan representatives described significant differences in their benefit arrays.

Representatives of only two plans described having implemented universal early intervention activities such as SBIRT. One Medicaid plan implemented universal SBIRT to screen for all alcohol and other substance misuse for all beneficiaries aged 12 years and older. One Medicaid plan representative described providers' initial hesitation to conduct SBIRT because of uncertainty about how to talk about substance use and competing priorities during the visit. The plan representative noted that SBIRT adoption into practice ultimately was driven by a statewide performance measure that put the plan financially at risk for uptake. The commercial plan implements a homegrown SBIRT-like model to screen for risk of alcohol use disorder but does not conduct screening for illicit substances. With the support of its research department, the plan staff developed an alcohol screening form in-house. Initially the commercial plan requested that clinicians conduct brief interventions using evidence-based motivational interviewing techniques. However, clinicians expressed discomfort with the process, and the plan shifted its SBIRT model to require that clinicians provide members with harm reduction advice prior to making a referral to a follow-up visit. To aid in this process, the commercial plan developed a loose script for clinicians to reference when giving advice. The script mirrors the way in which clinicians talk about diabetes care management and being above or below target levels. Clinicians inform plan members about guidelines for safe drinking, and then the clinician and plan member discuss whether the member's drinking behavior is above or below those guidelines. Harm reduction strategies such as reducing the number of daily drinks or binge drinking episodes are discussed with plan members exceeding safe drinking guidelines.

All six plans cover some medically monitored and medically managed detox services, although representatives from half of the plans described requiring either a prior authorization or some other type of access notification when plan members are admitted to these services. One plan in a non-expansion state covers only detox services for pregnant women. All plans cover outpatient treatment services without prior authorization. However, inpatient services, including intensive inpatient and partial hospitalization services, frequently were described as requiring prior authorization from health plans. Representatives from plans requiring some level of notification for any of these services indicated that the condition was not meant to limit or delay access to care but rather was a method of tracking members and identifying individuals in need of case management or care coordination services and follow-up.

Medicaid plan representatives described limitations on their ability to reimburse for residential treatment services because of state Medicaid policy. Four of the five Medicaid plan interview groups said that their state Medicaid agency did not include residential treatment in Medicaid benefits for non-pregnant beneficiaries. The representative from one Medicaid plan with a residential treatment benefit described being able to approve their members' residential services only in 7-day increments and with a total average length of stay of 30-days. Because of the state Medicaid benefit limits on residential services, most plan representatives described having their case managers and care coordinators outreach to community-based programs and grants to help members identify funding for residential treatment. In contrast, the commercial plan representative reported residential services as a covered benefit.

NALTREXONE
Representatives from only 1 Medicaid plan and the commercial plan indicated that they include naltrexone in injection form on their formularies. High cost was cited as a barrier for inclusion.

All health plans provide members with coverage of at least two MAT medication options for opioid treatment. All plan representatives reported covering buprenorphine or buprenorphine-naloxone medications as well as methadone. However, multiple plans described a preference for referring members to buprenorphine prescribers over methadone clinics because of plans' ability to coordinate member services with plan-affiliated prescribers rather than having to develop relationships and share records with external methadone clinics. The representative from one Medicaid plan also described a state policy that required beneficiaries to access methadone as a carved-out benefit through another state plan that specifically handled methadone treatment. Although the state recently had allowed its Medicaid managed care plans to coordinate benefits for methadone maintenance, the plan representative indicated that the plan's history with the carve-out model still deters the plan from promoting methadone. Representatives from only one Medicaid plan and the commercial plan indicated that they include naltrexone in injection form on their formularies. Plan representatives frequently cited the high cost of injectable naltrexone as a barrier to including it on their preferred drug lists.

Most plan representatives noted that they did not require prior authorization for MAT. They said that removing prior authorizations was important to ensuring access to necessary SUD treatment. However, one described maintaining prior authorization for all types of MAT. Although the state Medicaid benefit did not require prior authorization, the plan representative noted that it was beneficial to ensuring that the plan was knowledgeable about which beneficiaries were receiving these services. The plan also wanted to ensure that all beneficiaries initiating MAT also were participating in some other SUD treatment service such as one-on-one or group counseling. The plan representatives described their MAT service authorization similarly to how other plan representatives expressed a need for prior authorization on detoxification services. The approval was not meant to serve as an access restraint but to keep the plan informed about which beneficiaries were engaging in SUD treatment services and might require additional care coordination.

Naloxone formulations are included on all the interviewed plan drug formularies. None of the plan representatives described having specific coprescribing practices in place to direct providers to prescribe naloxone to members at risk for overdose. However, most indicated that they would be receptive to covering the cost of naloxone so that a beneficiary's family member could carry the overdose reversal medication in case of emergency. Leadership at three of the interviewed plans said that this topic had been discussed previously in meetings about improving SUD treatment outcomes. Representatives from the commercial plan were more familiar with providing naloxone to family members of beneficiaries at risk for overdose. Plan leadership described a state law that required plans to make the medication available to family members of beneficiaries at the same cost that the plan member would pay. Plan leadership was supportive of the legislation and the plan's ability to promote access to the life-saving medication.

Coverage of recovery support services was sparse among Medicaid plans. In some cases, peer supports are not a covered state benefit and, in at least one instance, the plan did not use peer support even though the state covered it. The commercial plan provides members with access to peer supports as part of their service buffet offered at all SUD treatment clinics affiliated with the plan. Their plan members have access to individual and group counseling as well as to educational groups focused on relationship building, anger management, depression, mindfulness, and other holistic recovery supports at the plan-affiliated clinics.

Although most Medicaid plans do not operate their own educational and recovery support groups, they do rely on outreach workers and case managers to identify community-based supports for their beneficiaries. Representatives from all but one Medicaid plan described sending outreach staff into the community to cultivate partnerships with external peer supports, education, and sober living organizations.

Quality improvement activities. Health plans engage in SUD treatment-related quality improvement in a variety of ways (Figure 10). Representatives from nationally branded plans and those with greater membership populations report employing large quality improvement teams that include statisticians and leadership to continuously monitor data trends in diagnostics and service use. Representatives from plans with limited resources or those without fully integrated EHRs described focusing on enhancing communication channels between beneficiaries and the plan and between case management teams and plan leadership to identify emerging needs of their covered lives. Almost all plan representatives also spoke about the importance of engaging with their provider population to promote uptake of evidence-based practices relevant to imitation and engagement in SUD treatment.

FIGURE 10. Quality Improvement Activities Used by Health Plans
FIGURE 10, Diagram: Map of quality improvement activities used by health plans, Representatives from nationally branded plans and those with greater membership populations report employing large quality improvement teams that include statisticians and leadership to continuously monitor data trends in diagnostics and service use.  Representatives from plans with limited resources or those without fully integrated electronic health records described focusing on enhancing communication channels between beneficiaries and the plan and between case management teams and plan leadership to identify emerging needs of their covered lives.  Almost all plan representatives also spoke about the importance of engaging with their provider population to promote uptake of evidence-based practices relevant to imitation and engagement in SUD treatment.

Health plans struggle overall to achieve full integration of their electronic medical records. However, multiple plan leadership groups reported investing significant resources in developing fully integrated physical and behavioral health records. Integrated records were described as a cutting-edge way for plans to more deeply understand their membership needs. Integrated health records allow health plan quality improvement teams to measure the frequency of acute care services or diagnostic risk factors for SUDs in their population. Plan representatives generally noted confidence in their ability to identify members with the most severe health needs. However, plan interviewees described investing in data analytics to identify members with moderate health risks and proactively outreach these individuals with additional supports. For example, one plan is conducting a monthly analysis of its pharmacy data to identify any members who billed for three or more narcotic prescriptions, dispensed by three or more pharmacies, with prescriptions written by three or more prescribers. The plan interviewee said that this monthly report generates a surprisingly long list of beneficiaries, including a significant portion who do not have any SUD or mental health diagnosis in their medical record. The plan then shares their monthly report with its care coordination team to identify next steps for member outreach.

Plan interviewees also described using integrated EHRs to track members' progression from a positive identification for substance use risk through treatment initiation and engagement over time. The commercial plan integrated a universal alcohol SBIRT screening form into their medical record. Any members who screen positive for risky alcohol use are flagged for follow-up. The plan generates a daily report of all members who are identified as having risky alcohol use and monitors those individuals for receipt of treatment referral and completion of follow-up appointments. A monthly report is generated for each plan-affiliated provider practice to identify members with a positive alcohol screen, the date of their positive screen, whether a referral was made, whether a follow-up appointment and assessment were scheduled and completed, whether the member has since initiated any SUD treatment services, and the name of the member's PCP. The plan implemented provider change leaders in each affiliated practice to support their effort. Change leaders are selected by the physicians within the local practice group and are responsible for reviewing the monthly reports with all physicians in their group. Change leaders are helping this plan bridge its advanced data analytic capabilities with more traditional quality improvement focused communication strategies.

All interviewed health plan representatives described open communication within the plan and between the plan and its membership as key to achieving improvements in SUD treatment. Communication strategies included using secure electronic messaging services to maintain real-time communication with providers concerning high-risk beneficiaries, including those with a newly diagnosed SUD. Similar to the intent of daily or monthly reports that identify members in need of follow-up services, plans are using secure messaging systems to send providers reminders to conduct follow-up calls and send outreach letters. Interviewees also described these systems as critical ways for providers to reach out to the plan directly, indicating whether the provider thinks that a plan member could benefit from care coordination or outreach efforts orchestrated by the plan. Providers can essentially "refer" a plan member for care coordination services to be provided by their health plan. Health plan care coordinators or outreach workers then phone the member to discuss his or her care needs. Outreach teams are trained on effective communication techniques to encourage members to engage in treatment.

CO-LOCATING SERVICES
Representatives from only 1 Medicaid plan and the commercial plan indicated that they include naltrexone in injection form on their formularies. High cost was cited as a barrier for inclusion. One plan stated that, prior to co-locating its SUD treatment counselors in primary care settings, only approximately 25% of the members they identified as in need of treatment actually initiated services.

Ensuring regular opportunities for open communication between care coordinators, outreach workers, case managers, and plan leadership including behavioral health medical directors were cited frequently as essential to improving treatment initiation and engagement. Every interviewed plan described some form of regularly scheduled in-person or conference call meeting for health plan staff members to discuss general treatment initiation challenges or to focus on strategies to improve outcomes for individual members with complex needs. As previously noted, many interviewees considered these regular meetings a critical way to keep plan governance leadership informed of membership needs. Interviewees from multiple plans described several occasions in which meetings between case managers and plan leadership resulted in the plan providing additional support to meet specific member needs. For example, interviewees described using plan funds to cover non-reimbursable costs for transportation or authorizing additional hospitalization days for members who otherwise would be discharged into unsafe living arrangements.

Overall, health plan interviewees expressed a substantial interest in maintaining communication between physical health and behavioral health providers. Primary care provider visits are seen as plans' first opportunity to identify the unmet behavioral health needs of their membership population.

Several plans described the importance of co-locating primary care and SUD treatment services as a way to improve treatment initiation. Interviewees described co-locating behavioral health counselors in primary care practices as critical to treatment initiation for patients who otherwise would not attend services provided in a behavioral health facility. One plan anecdotally described that, prior to co-locating its SUD treatment counselors in primary care settings, only approximately 25 percent of the members they identified as in need of treatment actually initiated services. Interviewees also use co-location as a strategy to overcome patient stigma around attending treatment services. The plan estimates that its SUD follow-up rate is now 80 percent. Embedding SUD counselors in primary care practices also was seen as improving communication between different specialty providers, which facilitated outreach efforts to plan members. If a member has disengaged from SUD treatment but attends a primary care or other medical appointment, the embedded SUD counselor can do a quick face-to-face visit to motivate that member to re-engage in services.

Many of the health plan representatives described plans to continue expanding efforts to co-locate services as a way to facilitate initiation in SUD treatment. For example, members with mental health needs frequently attend group sessions, which gives them little time to attend one-on-one or group SUD sessions. Co-locating these sessions in the same facility or developing more co-occurring group sessions for mental health and SUD issues would help more members initiate treatment for their SUD diagnosis. Plan providers described co-location as a critical part of their success in treating patients with SUDs.

Finally, health plans described provider education efforts as an essential piece of their quality improvement strategies. One health plan, however, expressed concern about burdening providers who must work with multiple insurers and indicated a disinclination to target education or initiatives directly at providers, but this plan did not hesitate to engage in quality improvement targeted at beneficiaries. Other plans were conscientious about not wanting to inundate providers with too much information but aimed to carefully disseminate information about targeted best practices in SUD treatment. Interviewees described developing monthly webinars, newsletters, and health plan meetings to promote understanding of evidence-based practices with providers. Interviewees described these efforts as a way to motivate providers while encouraging their accountability for quality health outcomes in the membership population.

Health plans reported investing significant resources in their quality improvement activities including developing new staff positions to support activities, investing in software to develop their data analytic capabilities, and establishing secure communications with beneficiaries and providers. Representatives from two of the Medicaid plans reported focusing their time and financial investments on initiatives that targeted activities related to service and quality measures for which they were financially at risk under the state Medicaid plan. These plans are motivated to maximize their returns on those metrics. Although many of the Medicaid plans are part of value-based purchasing at the state level, at the time of interview the majority of plans included in this study were not engaging in value-based payment arrangements with providers related to substance use metrics. At least two changes that are anticipated in the near future would involve providers in shared savings arrangements. However, all plans expressed an interest in closely managing their SUD population in an effort to manage overall costs. Generally, plan representatives expressed a concern that poorly managed SUDs would result in higher overall costs incurred at the emergency department or other ambulatory care service providers.

Qualitative Research Question 2: What other factors (e.g., patient, setting, provider, state, and local market characteristics) do health plans identify as affecting rates of initiation and engagement in SUD and OUD treatment?

Health plan interviewees described four key external factors they felt affected health plans' effectiveness at initiating and engaging members in SUD treatment services:

  1. Federal and state policies--specifically federal privacy and Medicaid-specific policies—were identified as major factors affecting health plans' ability to provide comprehensive services to meet membership needs.

  2. Stigma around SUD and mental health treatment was cited repeatedly as a major barrier to treatment initiatives.

  3. Plan member attitudes toward treatment and receiving support from their health plan were cited as substantially affecting treatment uptake.

  4. All health plan representatives cited a general concern over network adequacy for SUD treatment services as both a current concern and a major barrier to future access to treatment.

Policy factors. Health plans described federal confidentiality requirements of the 42 Code of Federal Regulations (CFR) Part 2 as specifically challenging to coordinating care for members admitted to detox and other inpatient facilities. 42 CFR Part 2 was established to restrict the disclosure of medical records describing an individual's diagnosis with an SUD or receipt of SUD treatment. The regulation requires individuals to provide consent to share any records pertaining to services received for SUD treatment. Several health plan representatives described detox facilities' understanding of the release of information requirements for 42 CFR Part 2 as overly burdensome to their ability to outreach to members prior to discharge and not reflective of the actual regulation requirements. Two plans addressed the recent amendments to the regulation and indicated that the amendments did not effectively address the needs of health plans to be able to coordinate care for their members. One interviewee characterized the recent amendment to the regulation as having "wasted an opportunity."

Multiple health plan stakeholders described learning of beneficiary detox admissions only after the beneficiary had been discharged from the facility. Case managers expressed frustration about being unable to engage in predischarge planning or identify new contact information on the plan members prior to their discharge. Case managers at one of the health plans described spending a significant amount of time working to improve their relationship with local detox facilities. The case managers are hoping that their positive relationships with the detox facilities will encourage facility staff to reach out to them, within the confines of 42 CFR Part 2, when their plan beneficiaries are admitted for detox services.

SHORTAGES OF RESIDENTIAL PLACEMENTS
One barrier to obtaining residential treatment for Medicaid health plan members is the prohibition against Medicaid reimbursement in so-called IMDs with more than 15 beds. This means that many Medicaid health plans do not reimburse for residential services. States, however, are increasingly seeking Section 1115 waivers to allow such reimbursement under their state Medicaid plans. Some health plans also seek residential placements with fewer than 16 beds so that reimbursement can be obtained. Despite these efforts, significant shortages of residential beds are reported, sometimes resulting in health plan members leaving detoxification and re-entering the community prematurely.

Each of the five Medicaid plan representatives interviewed identified policies emanating from their state Medicaid agency as factors limiting their ability to initiate and engage members in SUD treatment. Most of the Medicaid plans viewed restrictions on the types of services included in the state Medicaid benefit array as a substantial barrier. These included consistent restrictions on reimbursement for residential care given the federal prohibition on reimbursement for IMDs. Only one plan representative described the state service benefit as providing the full continuum of SUD treatment services, but with restricted ability to reimburse for residential treatment. Health plan representatives expressed a desire to cover additional treatment services not reimbursable by the state but ultimately noted that doing so was beyond their financial capability. Medicaid plan representatives described operating under a tight budget without sufficient funds to provide recovery supports outside of the state benefit.

State Medicaid policies that allow beneficiaries to frequently switch plans also were identified as negatively affecting health plans' ability to coordinate services. Many of the Medicaid plans interviewed had authority from the state to place beneficiaries in pharmacy or prescriber lock-in programs. Plan representatives described using these programs when beneficiaries were identified as receiving several prescriptions for controlled substances such as opioid analgesics from multiple prescribers or pharmacies. A few Medicaid plan representatives described placing beneficiaries in lock-in programs to monitor their prescription use while conducting outreach and case management efforts, only to have the beneficiary switch to another Medicaid plan mid-year. Some health plans reported frequent movement of Medicaid beneficiaries across state plans throughout a single enrollment year. One plan noted that the state Medicaid agency had further restricted movement between plans to control "plan shopping" to evade pharmacy and provider lock-ins.

BATTLING STIGMA
Health plans reported investing time in supporting community education about SUDs and the positive impact of treatment as ways to reduce stigma both in the community at large and in the minds of individuals who might need treatment.

Stigma. Health plan representatives commented on the ways in which stigma around SUDs and treatment hindered their ability to effectively initiate and engage members in treatment services. Health plans are cognizant of how community stigma toward SUD issues prevents individuals from identifying a personal need for care and reaching out for support. One interviewee who is actively working to cultivate working relationships between her health plan and local community organizations described the isolating effect of stigma. Although families experiencing a cancer diagnosis are supported by the community at large, families dealing with an SUD are not comforted in the same way. Other interviewees echoed this sentiment and described how neighborhood stigma can prevent their plan members from wanting to participate in recovery supports that do exist in their community. Health plans reported investing time in supporting community education about SUDs and the positive impact of treatment as ways to reduce stigma both in the community at large and in the minds of individuals who might need treatment. One plan also invested in remodeling its SUD treatment clinics to make them blend into the local neighborhood. The clinics do not include any signage identifying them as treatment facilities for SUDs or mental health conditions--rather their facades and waiting rooms are designed as non-specific medical practices.

Health plan representatives also described investing resources in reducing provider stigma around SUDs. Interviewees noted that providers often hesitated to conduct substance use risk screenings because they had not received adequate addictions training in medical school and were uncertain about how to talk to their patients about such issues. One of the interviewed health plans is hoping to improve provider-member conversations about SUD issues by training their members in self-advocacy. The plan sponsored an education class for members to learn about self-efficacy and communications strategies for addressing difficult topics including substance use and unmet care needs.

Health plan representatives also said that, although provider stigma related to treating members with an SUD has improved, many providers still were hesitant to take on new patients, especially those with Medicaid benefits. Plan representatives described conversations with providers expressing concern about Medicaid beneficiaries being disruptive in waiting rooms and burglarizing their practices for prescription drugs.

Members' competing needs and attitudes toward treatment. Interviewees described plan members' competing priorities including housing, child care, and accessing treatment for comorbid physical and behavioral health conditions as factors affecting successful initiation or continued engagement in substance use treatment services. Beneficiaries who are homeless or transient were identified as challenging to engage because they do not have stable addresses or phone numbers, which would facilitate outreach efforts. Most of the health plan representatives reported employing case managers and outreach workers based in the local community as a way to engage with community supports that their members might access.

Health plans also described efforts to provide members with transportation to follow-up appointments as a means of ensuring attendance. Health plans reported providing bus passes, reimbursing taxi costs, and providing gas cards to help individuals with limited finances overcome transportation barriers. Despite being able to offer these supports, case managers indicated that beneficiaries' attendance at follow-up appointments still was impeded by competing demands. For example, one plan representative explained that although members were provided a transportation benefit to get to their appointments, the state restricted children from accompanying members in the vehicle with them. Thus, to make their SUD appointment, beneficiaries with transportation and child care needs face the challenge of securing alternative transportation or a babysitter. Interviewed plan case managers said that most beneficiaries in this predicament simply do not attend treatment.

Health plan interviewees acknowledged that many of their beneficiaries with an SUD also have co-occurring medical and/or other health conditions that hinder their ability to attend SUD appointments or achieve medication adherence. Health plans responded by encouraging their care managers and outreach workers to meet members where they are and to prioritize member-identified needs. Health plan interviewees noted that implementing this approach resulted in the plan becoming aware of a member's need for SUD treatment, but it did not push the member to immediately engage in those services. Health plans focusing on this patient-centered approach noted that it was a strategy for keeping the door open to future SUD treatment.

Interviews also revealed that health plans are deeply concerned about being seen as a trustworthy resource to their members. Several health plans described member attitudes toward SUD treatment and health systems in general as a significant factor affecting their decision to initiate treatment. Health plan representatives noted that members often viewed the plan as an extension of untrustworthy state or other health care systems that they had encountered in the past. As a result, members were reluctant to respond to health plan outreach efforts. In response, these health plans are invested in developing positive relationships with community-based organizations that their members know. For example, one health plan representative described having the plan's outreach workers frequent community centers and treatment facilities that its members attend. Over time, the outreach workers became more familiar to both the community organizations and the plan members who frequent those centers. Integrating plan outreach workers in the community enabled the plan members to begin trusting the outreach workers and the health plan. Plan members now are more responsive to outreach efforts and care coordination from the health plan.

Requirements for access beyond network adequacy. All of the health plans described specific network adequacy requirements including limits on the mileage and travel time for beneficiaries to access treatment providers. Although each of the health plans are meeting these requirements set out by the state Medicaid agency and their governance boards, interviewees repeatedly described having additional network needs. Interviewees expressed concern over the growing need for treatment coinciding with decreases in the number of medical doctors specializing in SUD treatment. Health plan representatives focused most frequently, however, on how limited access to Drug Addiction Treatment Act of 2000 (DATA 2000)-waivered buprenorphine prescribers and residential treatment beds serve as barriers to meeting the treatment needs of their plan members.

NETWORK ADEQUACY ISSUES
Growing need for treatment coincides with:
  • Decreases in the number of providers specializing in SUD treatment.
  • Limited access to buprenorphine prescribers.
  • Providers who do not accept Medicaid beneficiaries.
  • Lack of residential beds.
  • Low reimbursement rates that limit plans' abilities to expand network adequacy for necessary services.

Health plan representatives described actively working on expanding their MAT provider networks. One health plan representative reported having its provider relations team conduct monthly outreach to assess which buprenorphine prescribers are accepting new patients. Representatives from this plan indicated that their efforts have not been successful in expanding their network adequacy for MAT. They consistently hear that providers do not have openings for their members; however, they are continuing to conduct monthly updates in case prescribers expand their practices. Other Medicaid plan representatives echoed this experience, noting that they find it hard to identify DATA 2000-waivered physicians willing to treat Medicaid beneficiaries. Interviewees said that prescribers would not to take on Medicaid beneficiaries because of preconceived notions about treating that population or because they were accepting cash only for office visit services.

Interviewees from each of the health plans were quick to identify specific challenges in contracting with sufficient buprenorphine prescribers to expand their treatment capacity. The amount of time spent on documenting buprenorphine treatment to meet DEA requirements was identified as a significant barrier for prescribers. One of the health plans is using grant funding to hire a Certified Alcohol and Drug Abuse Counselor to support a few of the local health plan-affiliated prescribers in multiple aspects of MAT provision, including meeting DEA documentation requirements. The counselor conducts educational consultations with the plan members about buprenorphine treatment, obtains informed consent, and schedules buprenorphine induction. All patient follow-up appointments take place with the counselor and the prescribing physician. Other health plan representatives described a desire to support prescribers in this way but reported lacking funds to pay for this support.

Additionally, health plans are concerned about the lack of beds available to their beneficiaries needing residential treatment facilities. Interviewees at the plan leadership and member outreach levels expressed concern over the lack of residential treatment facilities to which they could send their beneficiaries following discharge from detox services. Interviewees felt that, without residential treatment available to their members, they were watching them get discharged from detox only to relapse in the community without the appropriate level of care to support them.

Low reimbursement rates for both MAT and residential treatment were identified as significant factors limiting plans' ability to expand network adequacy for necessary services and ultimately to ensure access to care for plan beneficiaries. Medicaid plan representatives expressed an inability to contract with providers at reimbursement rates beyond the state rate. Medicaid plans expressed concern that providers withhold open spots from Medicaid beneficiaries to receive greater reimbursement rates from commercial plan members and individuals paying out-of-pocket. Leadership from the commercial plan expressed similar concern over the low rates that Medicaid plans can offer providers. Members of commercial plan leadership said that they are reluctant to reimburse residential treatment providers at rates substantially higher than those set by the state Medicaid agency. Previously the plan had set a higher reimbursement rate for residential providers, but in doing so they priced out the state Medicaid plans. Members of commercial plan leadership also reported reducing their reimbursement rates to help maintain access for Medicaid beneficiaries.

LOW REIMBURSEMENT
Low reimbursement was identified as a significant factor limiting plans' ability to expand network adequacy for necessary services.

The Medicaid plans do contract on an ad hoc basis with out-of-network providers to fill gaps in access. Payment is negotiated, and most of the Medicaid plans pay the same rate as they do for in-network providers. One plan paid less to provide an incentive to draw providers into the network. One paid more but did not want it widely known. Another plan representative indicated that paying more than a small amount above the state-established rate was burdensome because they would be required to justify doing so to the state.

Qualitative Research Question 3: What do health plan representatives believe are significant barriers and facilitators to initiating and engaging beneficiaries in SUD treatment?

Overall, health plan representatives did not feel that challenges to initiating members in care differed from the challenges to continued engagement in care. Plan representatives generally noted that any barriers to encouraging members to initiate care were the same barriers that made it easy for members to disengage after a few visits. In response, health plan representatives described identifying and developing facilitation strategies that applied to getting members to both initiate and continuously engage in care.

Key barriers identified by plans relate to community stigma toward SUD and treatment, providers' lack of addiction training and comfort treating individuals with an SUD, plan members' readiness for behavioral change, and service limitations of health plan benefit arrays. Because many of these findings already have been summarized in response to qualitative research Questions 1 and 2, the following section highlights key barriers and their associated facilitators.

Barrier: Community stigma toward SUDs and behavioral health treatment prevents members from initiating and remaining engaged in treatment.

Facilitator: Health plans are focusing on integrating primary care and substance use treatment.

Health plan representatives described substance use-related stigma as communities' rejection and alienation of individuals with an SUD. Interviewees said that communities do not regularly engage in conversations about substance use so it becomes a taboo subject when a community member has an identified need for SUD treatment. Interviewees described stigma around substance use as one of the most significant barriers to encouraging members to initiate and remain engaged in treatment. Health plan representatives identified substance use-related stigma as greater and more isolating than stigma around mental health conditions. Although interviewees noted that alcohol use disorder was less stigmatized than illicit SUD involving heroin or opioid analgesics, they identified overcoming stigma as a challenge to bringing beneficiaries into treatment.

Health plan representatives frequently described considering substance use-related stigma when developing strategies to successfully initiate beneficiaries in treatment. Most commonly, they focused efforts on co-locating SUD treatment services with primary care. Health plan interviewees identified member concerns about attending SUD-specific treatment facilities. Members did not want to be seen entering these facilities or have medical records specifically list the name of an SUD treatment facility. Interviewees noted that these concerns were particularly troubling for individuals who have not accepted their diagnosis, because they were more likely to perceive SUD treatment facilities as places for individuals with more severe treatment needs. Co-locating SUD treatment services within primary care and other physical health practices encouraged members to attend appointments in a familiar environment without the stigma of being identified as a behavioral health patient.

WARM HAND-OFFS
Providers were more comfortable having conversations about substance use risk behavior and treatment initiation with members knowing that they could perform a warm hand-off with the co-located counselor down the hall.

Specifically, most health plan representatives identified embedding SUD treatment counselors within primary care offices as their greatest facilitator to overcoming the beneficiaries' stigma around engaging in treatment. Interviewees said that providers were more comfortable having conversations about substance use risk behavior and treatment initiation with members knowing that they could perform a warm hand-off with the co-located counselor down the hall. Counselors were seen as being able to step in to talk to newly diagnosed members or members with risky behavior about the benefit of initiating some type of treatment. Interviewees also described how embedding counselors improved trust and communication between physical health and SUD treatment providers. Simply having these individuals in the same facility promoted regular conversations about integration and care coordination planning to support members' holistic needs. Interviewees described this integration as key to engaging in routine check-ins with members who are reluctant to initiate treatment or become disengaged over time. Primary care providers are able to repeatedly advise at-risk members about treatment and invite the counselor into the exam room to talk with members about their specific reluctance to initiating treatment. Similarly, co-located substance use counselors can check on members who come in for physical health appointments and make a subsequent effort to engage them in care.

Health plan interviewees described some initial pushback from providers regarding embedding SUD treatment counselors and other integration activities. Some providers told the health plan they felt that the behavioral health counselors were monitoring or infringing on their practice. Health plans responded by having plan leadership reach out to convince providers of the potential benefits of primary and substance use care integration.

Barrier: Providers lack sufficient training in addictions medicine to effectively initiate members in treatment.

Facilitator: Health plans are routinely engaging providers in education opportunities to promote evidence-based practices with substance use treatment.

Health plan interviewees identified primary care providers' lack of addictions training as a critical barrier to identifying risky substance use behavior in members as well as a barrier to encouraging members to initiate and engage in treatment. Interviewees described providers as generally reluctant to conduct screening for risky substance use. Interviewees said that providers reported not feeling comfortable asking the screening questions or knowing how to advise individuals who screened positive. Plan representatives acknowledged that early intervention activities were difficult for providers because substance use risk screening and motivational interviewing techniques were not adequately covered in medical school training. As a result, health plan interviewees described developing a variety of educational opportunities directed at enhancing providers' knowledge of best practices for substance use screening and treatment.

Health plans that require providers to conduct universal SBIRT with plan members reported developing training modules specific to using the screening tool and to conducting the brief intervention component for members with an identified risk. One plan representative reported holding provider training sessions on how to conduct motivational interviews with members. Providers practiced motivational interviewing techniques in person to develop confidence with the early intervention practice. Another plan reported abandoning the traditional motivational interviewing component of SBIRT in favor of having providers simply offer advice about reducing substance use. After providers reported feeling unsuccessful with the original motivational interviewing requirement, local plan leadership provided them with risk reduction talking points that mimic how providers counsel diabetic patients about glucose levels. Members are advised on the safe range of alcohol consumption and how much they would need to reduce consumption to be considered within safe medical guidelines.

Health plan representatives also reported developing electronic referral, messaging, and reporting tools to facilitate providers' efforts to initiate and engage beneficiaries in treatment. Multiple health plans invested in creating provider portals or other electronic systems to promote effortless communication between the provider and the health plan. Such systems are enabling providers to refer plan members to care coordination services and follow-up care with a single click. When this referral is made, health plans are alerted to the request in real-time and begin conducting outreach with the plan member. Health plan representatives said that they were motivated to create these tools to partially remove the burden of treatment initiation from primary care providers. Instead, the plan can outreach members directly to encourage treatment uptake.

Half of the health plan representatives interviewed also described generating provider reports on the number of members with an identified SUD and their follow-up treatment status. Interviewees noted that plan staff meet one-on-one with providers to discuss their performance and identify next steps for engaging members in treatment. Similarly, health plans are developing regularly scheduled meetings with providers to discuss best practices in SUD treatment. Plan interviewees described these in-person and webinar meetings as opportunities to inform providers about practices that close the gap between SUD diagnosis and treatment initiation. Meetings highlight the importance of referring members for care coordination and case management. Meetings also highlight best practices regarding MAT and ASAM criteria regarding level of care and care transitions. Health plans also are promoting materials developed by SAMHSA to augment provider knowledge around evidence-based practices in SUD treatment. Two of the health plans also reported partnering with local subject matter experts and university researchers to promote providers' understanding of the local populations' needs and attitudes toward SUD treatment.

Overall, health plan representatives noted that their many efforts to educate providers about substance use issues and treatment processes are helping them engage members in treatment. Most interviewees described wanting to serve as a support for providers and viewed the health plan and providers as part of the same team trying to bring members into care. Health plans are promoting this team sentiment by carefully scripting the way that they approach education with providers. Interviewees said that they were cognizant of not wanting to come off as telling physicians how to operate, but they want providers to see best practices and electronic systems as valuable tools for their patients.

Barrier: Members are not ready to abstain from substance use or other related risk behaviors, which results in an unwillingness to initiate traditional SUD treatment.

Facilitator: Health plans are promoting harm reduction techniques and "no wrong door" and "no wrong time" approaches to engage members in conversations about substance use.

Health plan interviewees identified beneficiaries' readiness to abstain from substance use as a significant factor affecting their ability to initiate or sustain engagement in treatment programs.

They described treatment programs and care management as historically focused on an abstinence-only approach with sobriety as a key requirement for continued engagement. Interviewees generally agreed that promoting abstinence-only treatment environments did not facilitate initiating members in treatment. As a result, health plan interviewees reported gradually shifting their approach to promoting harm reduction environments as well as abstinence programs. Representatives from several plans identified this shift to harm reduction as a significant facilitator for both initiating members in treatment and maintaining long-term engagement.

WHEN HEALTH PLAN MEMBERS DO NOT FEEL READY FOR TREATMENT
Health plans are more frequently promoting harm reduction techniques and "no wrong door" and "no wrong time" approaches to engage members in conversations about substance use.

Health plan representatives reported offering a variety of harm reduction initiatives to members. One plan began sponsoring group sessions that promote conversations between members who are reducing their use but have not fully quit. The plan representative noted that these groups have been useful for bringing more people into service who did not previously self-identify as needing treatment. The harm reduction groups were described as a place for members to begin thinking about what treatment would mean for them and what healthful behaviors are helpful to them in achieving their personal goals. Health plan representatives also described having care managers and outreach workers identify community-based harm reduction programs for members to participate in as a first step to reducing risky behavior.

Plans described harm reduction strategies as an extension of their intent to promote patient-centered care coordination and a "no wrong door" approach to SUD treatment. Health plan representatives described their no wrong door approach as enabling members to engage in any kind of treatment services, whether it be physical or behavioral health-focused, and then building a trusting relationship with the member to support initiation and engagement in SUD treatment. In developing an ongoing relationship with members, health plan interviewees noted that they can engage beneficiaries in treatment as soon as members express an interest. Thus, the no wrong door perspective also is facilitating a "no wrong time" approach to getting members into SUD treatment.

Discussions around the no wrong door approach focused on asking members about their priorities and health goals. Health plan representatives acknowledged that this approach was more easily promoted through their own care management and care coordination staff than through their contracted providers. The challenge with adopting this approach, according to interviewees, is that it requires a culture change from the way SUD treatment is traditionally viewed. Health plans are using their staff to promote a patient-centered philosophy rather than a program-centric approach.

Barrier: Health plan benefit arrays do not sufficiently cover the continuum of SUD treatment; this limits members' ability to initiate treatment or continue engaging in services that appropriately support their recovery needs.

Facilitator: Health plans are investing in staff that support members' access to community-based recovery supports and perform outreach to support treatment initiation and engagement.

One of the most significant themes identified in the health plan interviews is how health plans are focused on promoting a care coordination model that is based in mission statements about individualized and patient-centered care. This approach enables health plans to stretch beyond their stewardship of plan benefits to support beneficiaries with care management and outreach and to facilitate engagement in community-based recovery supports.

Plan-employed care managers, care coordinators, community health workers, and other outreach workers were identified as critical to successfully initiating and engaging members in treatment. Health plan interviewees repeatedly acknowledged that their ability to bring members into SUD treatment was contingent on their understanding that members have needs beyond traditional health services. Health plans are staffing their care management, coordination, and outreach teams with clinicians who are experienced and licensed and have a master's degree. Health plans expect these clinicians to conduct face-to-face visits as well as telephonic outreach with members wherever they are in the community. When plans learn of member admissions to detox or other inpatient facilities, these clinicians are expected to conduct immediate outreach with the member. Clinicians in these roles described reaching out to members to participate in discharge planning and care transitions and to coordinate community-based treatment postdischarge. Interviewees reported sharing their care plans with members' providers to facilitate ongoing treatment efforts and to integrate members' physical and behavioral health care.

Interviewees also reported a consistent expectation from their health plans to understand members' holistic needs across substance use, mental health, physical health, and necessities such as housing and food. Interviewees consistently described clinicians in these roles as "going above and beyond" for health plan members. But health plan representatives repeatedly described this level of member outreach as the primary facilitator of getting members to the initial SUD treatment visit and ensuring that they continued engaging long-term. Health plan interviewees noted that focusing on their members' individual needs enables their plans to identify key moments when members are receptive to treatment.

COMMUNITY PARTNERSHIPS
Interviewees reported establishing relationships with community-based peer support services, educational and employment support agencies, sober housing agencies, and other tenancy support organizations.

Additionally, interviewees at all five Medicaid plans identified limits on their covered services as restricting access to necessary treatment and recovery supports. As previously discussed, health plan representatives expressed frustration about not always being able to link their beneficiaries to partial hospitalization and residential treatment. Some of the Medicaid plans also were unable to reimburse for peer support services, which their representatives unanimously felt would facilitate their members' engagement in recovery.

Because of service limits within their own benefits, representatives from all five Medicaid plans reported cultivating community partnerships to expand their access to recovery supports across systems. Although they reported being unable to reimburse for these services directly, they can refer members to the services and help identify grant or donation funding for members when necessary. Interviewees reported establishing relationships with community-based peer support services, educational and employment support agencies, sober housing agencies, and other tenancy support organizations.

Care managers, care coordinators, community health workers, and other plan-employed outreach workers are expected to cultivate these community relationships to increase supports available to members. Health plan leadership frequently described these non-reimbursable services as key to promoting stability in members' lives and thus promoting their continued engagement in SUD treatment. Representatives from half of the plans interviewed reported encouraging their staff members to inform leadership about the success of these community partnerships. They described efforts to track and report on member progress as a means of producing evidence that might support possible inclusion of these services in the plan benefit array in the future.

Facilitators and Barriers to Measurement for HEDIS IET

The primary aims of the qualitative interviews and analyses were focused on identifying characteristics, strategies, and other factors that affect the ability of successful health plans to initiate and engagement members in care. However, several health plans also wanted to discuss ways in which they view the criteria of the HEDIS IET measure as affecting their measured success in initiating or engaging members in treatment. The following themes are drawn from brief conversations with health plans around the structure or calculation of the HEDIS IET measures.

Health plan representatives expressed concern about the timeline by which the IET measure requires them to meet the initiation and engagement phases of the measure. The initiation phase requires individuals to receive inpatient or outpatient treatment within 14 days of an initial SUD diagnosis. Health plans have a total of 30 days from the member's first visit in which to complete two additional treatment visits and achieve engagement. Health plan representatives indicated that they often did not receive claims data on their members within those time frames, and thus they were unable to ensure that members receiving an initial diagnosis completed initial and follow-up visits in time to count toward the measure. Plan representatives noted that if they failed to receive timely notice of a member's initial detox admission, they likely would fail both the initiation and engagement phases of the measure.

Health plans also commented on the measure's requirement that the initial diagnosis and initial outpatient or inpatient visit occur with different providers if they are completed on the same day. Representatives from two of the health plans commented that they had previously encouraged diagnosing providers to walk members into follow-up appointments with different providers in order to meet the initiation phase. One reported having financially incented providers to conduct this warm hand-off. Health plans enjoyed the option to count same-day appointments toward the measure requirements and expressed concern over the criteria being changed to require that all visits occur on different dates.

Finally, one health plan representative noted that the measurement criteria used for commercial and Medicaid beneficiaries should differ. Plan representatives described how general sociodemographic differences between commercial and Medicaid beneficiaries should alter the expectations for treatment initiation and engagement timelines. The health plan interviewees specifically highlighted challenges in locating Medicaid beneficiaries who are homeless or otherwise hard to reach. Plan interviewees noted that the timeline for meeting the initiation and engagement phases of the measure should be extended for Medicaid populations.