Best Practices and Barriers to Engaging People with Substance Use Disorders in Treatment. SYNTHESIS OF FINDINGS AND STUDY IMPLICATIONS

03/06/2019

The opioid crisis has worsened a pre-existing failure to adequately provide SUD treatment to many in the United States who desperately need it. Many people in need of treatment do not attempt to access it, and many who try find access difficult or impossible. As shown in the section of this report on Health Plan Trends for the IET Measure, evidence for this worsening crisis may be found in health plan data from across the country, which show declining rates of initiation and engagement in SUD treatment between 2005 and 2014.

To identify factors associated with successful treatment initiation and engagement, including health plan strategies that may increase rates of involvement in treatment, this study looked at models of care, reimbursement, interventions, and best practices that higher-performing health plans use to improve initiation and subsequent engagement in SUD and OUD treatment. We also examined market, provider, and beneficiary factors that affect plan performance in that area.

Our primary focus was to understand how health plans successfully get beneficiaries into SUD treatment and keep them there. For convenience, both in developing quantitative analyses and in identifying health plans to approach and interview, study researchers relied on the HEDIS IET measure. Our real interest, however, lies not in initiation and engagement as defined by that measure, but in initiation and sustained participation in treatment for as long as the individual patient may require. The IET measure is a tool that got researchers to the point of being able to examine factors that influence initiation and engagement more broadly defined.

Our quantitative analyses linking beneficiary, plan, and market characteristics to commercial health plans, as well as subsequent semi-structured interviews with high performing plans, elucidated key influences identified in the theoretical model (previously described in Figure 1), which, in turn, derived from the existing literature reviewed as part of the environmental scan.

Individual Influences on SUD Treatment Participation

Published literature identifies several individual-level influences on SUD treatment participation. These include individual beliefs and attitudes such as stigma, individual demographic characteristics that may be associated with higher or lower rates of treatment involvement, the nature of a person's substance use (e.g., injection vs. ingested), the person's past experience of SUD treatment, the presence of co-occurring mental health conditions, and level of patient activation. Individual influences most often revealed as affecting initiation and engagement in this study include the individual's sex, competing needs, co-occurring conditions, stigma, and treatment readiness. Successful plans have implemented initiatives designed to address these variables.

Most characteristics that fall within the category of individual influences on initiation and engagement could not be analyzed in the quantitative analyses, but multivariate regressions did show that plans with more female beneficiaries were less likely to perform well on the measure of engagement in SUD treatment and OUD treatment. This finding is consistent with results in the existing literature.[7, 8, 9, 10] Interviews confirmed that health plans have found it harder to engage females than to engage males and indicate that this difference often may result from competing needs, including child care and transportation, that interfere with access to SUD treatment. A woman also may fear loss of custody if she is pregnant or a mother and acknowledges having an SUD and seeks treatment. Approaches that some plans have taken to address the problem of competing needs include the provision of child care to facilitate treatment for mothers and the establishment of a woman's center that specifically addresses pregnant women's treatment needs. As addressed in the results, however, efforts to address these competing needs that are more commonly experienced by females have met with mixed success but have been shown to close the treatment gap, in some cases.

In addition to competing needs such as child care and transportation, health plan interviewees identified homelessness and co-occurring mental disorders as factors that compete with attention to SUD treatment. Those who are homeless can be difficult to reach, and being homeless makes treatment attendance more difficult. Although health plans do not pay for housing, care managers and outreach workers can and do work with beneficiaries to assist in obtaining housing that can facilitate treatment. Similarly, co-occurring mental illness can impede treatment initiation and engagement,[156] because mental illness and SUD negatively affect each other if both are not addressed. Yet, a person's ability to attend to both may be limited. Health plan efforts to identify and implement initiatives that integrate SUD and mental health care services seek to provide improved ease of access for care that addresses co-occurring conditions. These and other potentially competing needs get in the way of treatment participation. Increased focus on social determinants of health by health plans requires resources that many may not have.

As the literature indicates,[12] stigma is a powerful barrier to care, and plans that have reached out to educate communities about SUD and the positive effects of treatment are taking steps to alleviate stigma. Nearly all of the plan representatives with whom we met mentioned the issue of stigma associated with SUD. Individuals may feel stigmatized by attitudes in the community, by providers, or even by their own family, which may prevent them from seeking treatment or, sometimes, even acknowledging the problem.

COMPETING NEEDS
Women historically have been more difficult to engage in SUD treatment. Competing needs such as transportation and child care may play a role. Addressing those issues may facilitate increased initiation and engagement for women.

Plans have reached out to educate communities about SUD and the positive effects of treatment, seeking to alleviate such stigma. This education also may increase patient activation, which is a contributor to treatment participation.[62] Plan representatives also cited instances in which plans can provide SUD treatment that is fully integrated into treatment for physical health as examples of successfully circumventing fears associated with stigma. Patients who do not have to enter a building specifically designated as an SUD treatment facility but instead can use the same facilities where they access other medical care are less fearful of being identified as in SUD treatment. Co-locating SUD and physical health treatment, however, often is in the hands of providers rather than plans. Integrated systems and small plans that incorporate providers appear better suited to address the physical manifestations of care that may alleviate stigma than do larger plans that contract with a host of providers in various care settings and that may have difficulty filling their networks regardless of care coordination or co-location capacity. It seems, however, that efforts to integrate care, co-locate services, and provide education all can serve to both help alleviate stigma and address conditions that co-occur with SUD.

The literature indicates that younger people in particular may be more comfortable with a harm reduction approach to treatment than with an abstinence-based approach.[124] To address the fact that many patients may not be ready to abstain from substance use, health plans increasingly are shifting their approach to promoting harm reduction environments rather than abstinence-driven programs. The need to engage people in treatment, even if the goal is harm reduction, is important when the only alternative may be continued use at high rates, resulting in overdose and exposure to additional health risks.

Provider Influences on SUD Treatment Participation

Provider characteristics also were identified as influencing treatment initiation and engagement. Many health plan interviewees reported feeling that provider stigma about treating patients with an SUD, or Medicaid patients generally, interfered with providers' ability or desire to encourage members to initiate SUD treatment. Related to this provider stigma is provider discomfort with the subject matter and lack of expertise. Previous research suggests that many PCPs do not feel competent about their ability to treat patients with an SUD. Physicians cite a lack of addictions-focused training, personal stigma, and time constraints as limiting their ability to screen for SUD or link patients with risky behavior to treatment services.[13, 14, 15]

Many health plan representatives interviewed in the present study described developing a variety of educational opportunities directed at enhancing providers' knowledge of SUD issues in general, as well as evidence-based and other best practices for substance use screening and treatment. However, one plan expressed reluctance to target initiatives to providers because plan staff members fear overwhelming providers with information on new initiatives, tools, and other SUD-related information. This plan seemed to focus its efforts more extensively on patients than on providers, whereas the remainder of plans attempted both. Upon reviewing the relative rankings of this plan with the others on IET, researchers found initiation in the 85th percentile and engagement in the 95th percentile, with good performance on other behavioral health measures as well. This limited information does not allow any conclusion to be drawn on the preferability of one approach over the other.

Provider shortages also are a factor that can limit SUD treatment initiation and engagement. For example, 53 percent of all counties in the United States lack any waivered buprenorphine prescribers.[87] These and other shortages were mentioned throughout the interviews as impeding access to care. Efforts that plans do make to address provider expertise and attitudes logically should alleviate provider shortages to some extent as well. Plans did describe outreach and other approaches to induce providers into their networks; however, solving the problem of provider shortages clearly is not simple, given absolute provider shortages, providers only accepting cash, and other factors impeding adequate coverage of beneficiary needs. Shortages of individual providers such as addiction specialists, psychiatrists, and buprenorphine prescribers, as well as residential treatment, detox facilities, or OPTs, combine to make access to the right level of care at the right time difficult for many plan beneficiaries. To some extent, these shortages are associated with the lack of available expertise and provider desire to work with patients with an SUD. They also pertain to network adequacy--a factor discussed later regarding health plan-related factors influencing initiation and engagement. However, addressing workforce shortages and adequacy of reimbursement and working to reduce stigma are important to alleviate shortages. Further, finding incentives to encourage providers to accept insurance or to deincentivize the demand for cash is worth exploring to boost the inventory of available providers for individuals with an SUD.

Market and Environmental Influences on SUD Treatment Participation

Existing literature indicates that SUD treatment gaps often are found in the South, Southwest, or Midwest and that OUD treatment gaps are greatest in the Great Plains and in the Southeast.[87] As a result, the current study aimed to interview health plans in geographically diverse locations including the Northeast, Southeast, Midwest, and West. Geographic and policy elements interact within this study because two of the interviewed Medicaid plans operate under state policies that have not expanded Medicaid eligibility and benefits in response to the Affordable Care Act--with one located in the Southeast and the other in the Northern Midwest region. Although both of these non-expansion Medicaid plans were higher performers on the IET measures, more limited Medicaid coverage may have positively affected initiation and engagement rates by eliminating substantial segments of the population with an SUD who might have been covered in other states. Further, because of limitations in the state Medicaid plan, one of the plans in a non-expansion state did not reimburse for certain services (e.g., IOP and partial hospitalization, peer services) that were routinely covered services for plans located in expansion states.

In the qualitative component of this study, health plan interviewees identified two national policies as significantly influencing treatment participation. Many interviewees cited the regulation at 42 CFR Part 2 as interfering with plans' abilities to coordinate care, most often with detox facilities or specialty substance use inpatient facilities. One plan representative hypothesized that specialty facilities are more familiar with the regulation and thus more hesitant to share information about admission or treatment for SUDs, whereas general hospitals may be less aware of 42 CFR Part 2 and more likely to operate under the assumption that the standard confidentiality provisions apply to all services.

Interviewees from two different health plans made it clear that they regarded the recent amendment to the regulation as having "wasted an opportunity" to expand the ability of health plans to coordinate care for their enrollees. To address this issue, some plans impose prior authorization or notification requirements that allow them to know in advance that an enrollee will be admitted, permitting them to follow up. Others are involved in extensive efforts to work closely with detox facilities or hospitals to ensure that there is an ongoing close relationship and trust and to facilitate systems that permit notification of enrollee admission that will allow timely follow-up. In an era when efforts are being made to get away from prior authorization in the treatment of SUD, it appears that it does have a role to play in situations such as this, although notification rather than authorization may be a subtle difference with fewer reimbursement repercussions. Rather than being required to engage in these workarounds, however, health plans clearly would prefer either that the regulation be amended or that the provider community better understand that plans' ability to know what is happening with their beneficiaries is critical to effective care coordination. The plans obviously see themselves as responsible for care coordination and perceive the regulation as a substantial barrier impeding their ability to carry out that responsibility.

Another federal policy mentioned was the restriction on Medicaid coverage of care in IMDs. Only one of the five representatives from Medicaid plans we interviewed discussed trying to identify residential facilities with fewer than 16 beds in order to provide their members access to Medicaid-reimbursable residential treatment. Representatives from this Medicaid plan and the one commercial plan interviewed both expressed frustration over the limited number of residential treatment beds available in their communities, regardless of IMD constraints. Under the current Section 1115 SUD delivery system waivers, an increasing number of Medicaid plans will be able to reimburse for residential treatment.[20] However, access may remain limited because of a general shortage of residential treatment capacity. Given that bivariate results from the quantitative analyses indicated that the commercial plans reimbursing for residential treatment had higher rates of treatment initiation, one hopes that the loosening of reimbursement might encourage an increase in the number of beds available if payment is an option.

Analyses revealed different ways in which state policies and other state characteristics influence treatment initiation and engagement. For example, multivariate analyses indicated that higher rates of initiation of OUD treatment were associated with being in a state with a higher-than-average prevalence of opioid prescriptions in relation to the state's population. This finding is logical, assuming that higher rates of opioid prescribing are associated with higher rates of OUD and higher demand for OUD treatment.

In quantitative analyses, initiation of OUD treatment also was negatively associated with being in a state where prescribers or dispensers are required to access the PDMP in certain circumstances. This result simply may mean that identifying problems with opioid prescribing or identifying doctor or pharmacy shopping does not translate to referral to OUD treatment. Interviews with health plan representatives revealed mixed perspectives on the utility of PDMPs. Interviewees reported significant variation in PDMP use in states without laws requiring PDMP consultation prior to prescribing, dispensing, or both. However, plans generally expressed a desire to use data in ways that would allow them to better identify problems of misuse and target treatment initiation and engagement efforts toward those identified as obtaining inappropriate controlled substance prescriptions. Although health plans can and do use their own claims data for information on prescription fills paid by the plan, access to PDMP data would allow the plans to know whether beneficiaries were filling excessive or unnecessary prescriptions and paying for them with cash, thereby circumventing plan lock-in policies. Recent research using PDMP data has revealed that the implementation of pharmacy lock-ins may result in increased out-of-pocket payment for prescription opioids,[157] supporting plan arguments that access to those data would be useful in curtailing opioid misuse.

Interviews with health plans revealed additional circumstances in which state policies may impede or facilitate SUD initiation or engagement. For example, state Medicaid agencies limit what their associated Medicaid health plans can reimburse for services such as peer support and recovery services. Some plans accept this state benefit restriction, whereas others find ways to help beneficiaries access peer services in the community. State Medicaid policies that allow beneficiaries to frequently switch plans also were identified as impeding plans' abilities to coordinate services and as permitting patient evasion of plans' pharmacy lock-in policies. One state was reported to have imposed additional limitations on the freedom of Medicaid beneficiaries to change plans, thereby mitigating some "plan-shopping." Low Medicaid reimbursement rates and, in one case, substantially delayed reimbursement from the state agency, also were identified as significant factors limiting plans' ability to expand network adequacy and ensure access to care for beneficiaries. Medicaid plans expressed concern that providers withhold open spots from Medicaid beneficiaries so they can receive greater reimbursement rates from commercial plan members and individuals paying out-of-pocket. States struggle with these factors that stem from state Medicaid policies and, ultimately, budgetary considerations that impede the ability of Medicaid plans to engage providers and serve their beneficiaries.

State policies that provide for coverage of MAT or that preclude the use of prior authorization for MAT or other SUD services can encourage easier access to needed treatments and facilitate initiation and engagement in treatment. As noted earlier, however, plan use of prior authorizations for notification purposes can facilitate treatment if it has the effect of alerting the plan to patient admission to a detox facility in real time, thereby allowing follow-up prior to discharge and subsequent initiation or engagement in step-down treatment. Unfortunately, use of prior authorization also may have the effect of making prescribing sufficiently more difficult if it creates an unnecessary barrier to care.

Health Plan Influences on SUD Treatment Participation

Our review of the literature found three overarching types of health plan interventions that have been used to improve initiation and engagement in SUD treatment: (1) implementation of evidence-based clinical practices; (2) interventions that may better address the needs of special populations; and (3) organizational interventions. Our quantitative analyses and analysis of health plan interviews provided us with additional insight into these three categories. As already mentioned, health plans may focus some of their quality improvement efforts on increasing provider knowledge of SUDs and SUD treatment and on accelerating use of evidence-based practices, including MAT. Health plan interventions that address the needs of special populations may include interventions: (1) in collaboration with schools or with local law enforcement or other correctional systems; or (2) that focus on women who are pregnant or parenting or on beneficiaries who are homeless. Health plans also must take account of variable substance use in their populations. For example, identifying beneficiaries at moderate risk of having an SUD may be difficult, and plans increasingly are using pharmaceutical claims mining to find individuals, for instance, who are obtaining excessive opioid prescriptions and targeting outreach to those individuals, as well as imposing pharmacy or provider lock-ins. This drug utilization review approach is supported by CMS[20] and is advocated as part of the HFPP. The HFPP encourages the use of data, among other things, to identify patients at risk of opioid misuse and OUD and to intervene on the basis of those findings.[142] Further, although opioid use receives the most attention, alcohol remains the drug used most pervasively and, in some areas, other drugs such as cocaine or methamphetamine are commonly used, and individual health plans must find ways to address related use disorders appropriately.

Both quantitative and qualitative analyses identified organizational-related interventions as significant factors in increasing treatment uptake. Some of the current study's reported findings echo those identified in the existing literature, but we also gathered considerable new information, providing insights into strategies and structures of health plans that are successful at initiating and engaging beneficiaries into SUD treatment.

INTERVENTIONS
Our review of the literature found 3 overarching types of health plan interventions that have been used to improve initiation and engagement in SUD treatment: (1) implementation of evidence-based clinical practices; (2) interventions that may better address the needs of special populations; and (3) organizational interventions.

Health Plan Structure

Bivariate quantitative analyses showed that plans with the largest numbers of beneficiaries tended to have the lowest rates of initiation and engagement for both SUD and OUD, as did plans with higher percentages of beneficiaries with an SUD or an OUD. To some extent, this result may be explained by observations from the health plan interviews. The health plan representatives we interviewed were from one small local plan, four medium-sized regional plans, and one large national plan. All but the small local plan had a multilevel system of governance, with both corporate and local oversight of mental health care and SUD services and different degrees of local versus enterprise-level oversight of utilization management, care management, care coordination, and quality improvement. However, all the regional or national insurance companies stressed that some level of local decision-making was critical to implementing behavioral health policies and procedures in ways that responded to local population needs. These plans relied heavily on local leadership, with state-specific plan presidents, medical directors, and behavioral health directors overseeing regionally stationed case management and care coordination teams. Interviewees repeatedly endorsed regular communication between corporate and local leadership, as well as internal communication at the local level, as critical to address beneficiary needs or access challenges. A locally focused approach with ample communication may be one of the ways in which the plans selected for interviewing differentiate themselves from others that may fare more poorly on initiation and engagement, if lack of local governance and local initiatives are more limited among the latter.

Although the national plan interviewees indicated that their plan depended more on corporate oversight and noted that their approach enabled them to streamline decision-making and ensure consistency across their business lines, the results of their IET rates were not distinguishable from those of the other plans interviewed. It may be more telling, however, that only one of the six plans interviewed had a clearly more centralized approach, suggesting either that smaller plans are simply more willing to submit to interviews or that a localized approach is more likely to place a plan in the upper echelons of IET results. Without better understanding of the governance of poorly performing plans, conclusions cannot be drawn regarding whether a more locally focused approach is preferable.

Reimbursement and Benefit Design

It appears that the provision of more components of the SUD care continuum influence initiation and engagement rates. Multivariate quantitative analyses showed that higher-performing health plans for both SUD and OUD initiation and engagement provided more IOP or partial hospitalization services than did lower-performing plans. SUD engagement was associated with increased outpatient services as well, whereas, in bivariate analyses, provision of residential services was linked to higher initiation rates. Representatives from the six plans that we interviewed all discussed the importance of reimbursing for the full SUD care continuum. Plan interviewees frequently compared the extent of their SUD service benefit with their ability to bring members into SUD care services. When more intensive services such as partial hospitalization and residential treatment were unavailable, some health plan representatives described finding other creative ways to engage members in inpatient, outpatient and community-based recovery support services. Although the state Medicaid agency sets service benefits for five of the interviewed plans, some of their leadership and care coordination teams viewed benefit design as having some mutability and capacity for augmentation via community partnerships through coordination of a patchwork of available services to substitute for unavailable treatment options.

Quantitative analyses indicated that out-of-pocket costs and provider reimbursement are other factors affecting treatment uptake. Our multivariate analyses found that commercial plans with higher rates of SUD treatment initiation had higher-than-average median out-of-pocket costs for outpatient SUD services per user. Bivariate analyses showed similar associations between higher performance on SUD initiation and engagement and higher out-of-pocket outpatient costs and outpatient reimbursement. The same was largely true for OUD treatment. These results may not necessarily mean that those commercial plans imposed higher co-pays or deductibles. Indeed, bivariate analyses showed that high-deductible plans fared more poorly on the IET rates. Instead, it may mean that, for those who require SUD services, more services are provided and, with each of those services, a co-pay accrues, increasing the overall out-of-pocket cost to the person for multiple aspects of treatment. This interpretation makes sense, given that a higher quantity of outpatient services per beneficiary also was associated with better initiation and engagement. There is, however, no assurance that the same result would be obtained in a Medicaid population, and the high performing Medicaid plans examined in this study did not require any out-of-pocket expenditures. Medicaid plans also generally reported not requiring members to face out-of-pocket costs for services available only from out-of-network providers. When out-of-network providers were identified as necessary, the health plan representatives reported either contracting with the provider to come into network or making special one-time arrangements to reimburse for services at no costs to members.

In contrast to outpatient results, bivariate results showed that inpatient out-of-pocket costs and reimbursement were lower for commercial plans that did better on SUD and OUD initiation and engagement. This suggests that plans that rely more on intensive and more costly inpatient services are not successfully taking that next step of initiating beneficiaries into treatment and finding ways to keep them in treatment. Thus, rather than reimburse for less-costly outpatient services, these lower-performing plans may rely more on hospitalization and little else.

There were paradoxical results among the bivariate analyses related to costs and reimbursement of MAT as part of OUD treatment, all of which potentially provide evidence that improved coverage of MAT is associated with improved initiation and engagement in OUD treatment. Higher rates of OUD treatment initiation were associated with higher out-of-pocket costs and higher pharmacy reimbursement for MAT medications, which may relate either to higher co-pays within the commercial plans or to more permissive induction dosing with accompanying higher costs. In contrast, higher rates of engagement were associated with lower out-of-pocket costs and pharmacy reimbursement for MAT medications, suggesting that, for commercial patients, longer-term use of MAT may be more price sensitive. Bivariate analyses of duration of MAT treatment found that higher-performing plans on both initiation and engagement in OUD treatment more commonly reimbursed longer periods of MAT treatment (more than 14 days) than did lower-performing plans. Among the health plans interviewed, all covered at least two opioid MAT drug options--all covered buprenorphine or buprenorphine-naloxone and methadone. In other words, all of the health plans selected for interview perceive MAT to be an integral part of treatment and treat it accordingly within their reimbursement structure.

Network Adequacy

On the basis of distance and number of providers proximate to beneficiaries, health plans impose internal standards and/or must meet state requirements for network adequacy. Although the health plan representatives interviewed reported satisfying their requirements, all indicated that these requirements are not always sufficient to ensure adequate access. Many of these requirements related to the number of addiction specialists, buprenorphine or methadone prescribers, and detox and residential facilities.

Health plan representatives interviewed consistently stated that finding buprenorphine prescribers for beneficiaries often was difficult. Many areas lacked waivered prescribers and, where there were waivered prescribers, many did not accept patients or did not accept Medicaid patients, often preferring cash payments. Health plan interviewees described efforts to expand their MAT provider networks, and one health plan interviewee reported conducting monthly outreach to assess which buprenorphine prescribers are accepting new patients. Methadone availability also sometimes was lacking. The small Medicaid plan had worked with a methadone provider located elsewhere in the state to open a new OTP in a town near the plan's center of operations, allowing enhanced access for its beneficiaries. Detox facilities and residential treatment facilities for placement after detox also often were lacking. Even though most plans could not reimburse for residential treatment, if payment was available from other sources, treatment settings sometimes were not. When asked about use of telehealth to expand capacity, several plans reported not using it for SUD treatment.

These findings suggest both that alternative approaches to assessing network adequacy and that alternative approaches to ensuring treatment access deserve further attention from researchers and policymakers. If SUD treatment is cost-effective, investing in options for treatment access makes sense to further treatment access and to conserve overall resources.

Integration, Care Coordination, and Care Management

All health plans interviewed have taken significant steps toward integrating care, including physical health, mental health, and SUD treatment. These steps range from conducting patient-focused and provider-focused interventions such as requiring universal mental health and substance use screening by physical health providers or co-locating SUD counseling services in physical health settings to internal plan-focused efforts that involve team meetings that can address multiple aspects of individual beneficiaries' needs. Interviewees clearly took a holistic view of member needs and were focused on collaborative efforts between plan leadership, clinicians, and plan members.

INTEGRATED CARE
One of the primary tools to facilitate integrated care, as well as improve initiation and engagement in SUD treatment, was the use of plan-based care coordinators, care managers, and outreach workers.

One of the primary tools used to facilitate integrated care, as well as improved initiation and engagement in SUD treatment, was the use of plan-based care coordinators, care managers, and outreach workers. Interviewed plans placed an emphasis on maintaining a balance of such staff members who relied on phone contact and others who worked with beneficiaries in the community, including conducting house calls or meeting them in hospitals or detox facilities. Several health plans also promoted cross-system integration by working with schools, law enforcement, providers for homeless individuals, or services for pregnant women.

These health plan care management and coordination positions, and the staff efforts to augment reimbursed services, integrate care, and pull individuals with an SUD into treatment, are clearly critical to allowing the currently high performing plans to do well on the IET measure. Increasing mechanisms to pay for care coordination and management, as well as cross-system integration, will be important to improve SUD treatment initiation and engagement across a broader range of payers beyond these that are currently higher-performing.

Quality Improvement Initiatives

Health plans reported investing significant resources in quality improvement activities, expressing a concern that poorly managed SUDs would result in higher overall costs for the plan and inadequate care for beneficiaries. Quality improvement efforts have included developing new staff positions to support activities, investing in software to develop data analytic capabilities including data mining, and facilitating secure communication with beneficiaries and providers.

Although plans that are not provider owned did not engage in shared savings with providers, two interviewees mentioned plans to begin, possibly as a pilot or as part of a state Medicaid ACO initiative. A number of the plans, however, are themselves subject to alternative payment models such as value-based payment or pay-for-performance models designed to incentivize desired behaviors or outcomes as part of quality improvement. In the case of Medicaid plans, a state will establish certain performance measures (e.g., IET or follow-up after hospitalization) as metrics to which payment may attach. States may implement shared savings, whereby higher performance results in payment to the plan, and/or may tie metrics to payment withholds, whereby the health plan is penalized financially should it fail to meet predetermined state benchmarks on SUD measures.

Two of the Medicaid plans reported focusing their time and financial investments on initiatives that targeted activities related to quality measures for which they were financially at risk under the state Medicaid plan. They are very motivated to maximize their returns on those metrics. Plans described organizing leadership, contracting teams, and member outreach employees to develop and engage in extensive, measure-focused innovations that target multiple aspects of health plan organization, communication strategies, and relationship building with providers and beneficiaries. Health plans also closely attend to the importance of changing their approach and being sensitive to state-directed modifications to measures and payment arrangements. As states shift their emphasis to new measures or redesign the way in which benchmark metrics can be achieved, plans are actively adjusting their approach and identifying new ways to meet these expectations.

This raises three issues for policymakers:

  1. Health plans that are not doing well on initiation and engagement either may not be subject to a pay-for-performance model or may completely lack the resources to respond, and policymakers should understand and address either circumstance.

  2. The measures that policymakers select to incentivize must be measures that really assess something that is very important to encourage because the focus on those measures may reduce focus in other important but unincentivized areas.

  3. Removal of a good measure from the group to which incentives attach may result in loss of focus and declining performance if the initiatives undertaken to improve performance on that measure no longer are sustained.

Study Limitations

Although this expansive mixed-methods study presents and synthesizes valuable quantitative and qualitative data, like all studies it has limitations. The rapid change that has taken place in recent years in health care generally, and in behavioral health care in particular, means that managed care plans identified for potential interviews based on 2014 results on the IET measure were somewhat different when staff members were interviewed in 2017. Plan personnel, plan structure, and plan initiatives all changed in the intervening 3 years. Thus, the positive rates of initiation and engagement in 2014, as well as plan strategies for improving SUD treatment participation, may have continued, grown, or decreased. This means that information gathered in interviews represents more closely the status in 2017 than that in 2014.

Another limitation related to the mixed-methods approach involves the fact that the quantitative analyses used commercial insurance data, yet the qualitative interviews were primarily with Medicaid plans. Obtaining access to representatives of high performing commercial plans for interviews was much more difficult than scheduling interviews with representatives of Medicaid plans. Although this limitation represents a difference between the quantitative and qualitative aspects of the study, it may provide the benefit of balancing the information gathered.

Finally, some variables used in the quantitative analyses may not have completely captured the sort of information that was intended, particularly among the market and environmental characteristics variables. For example, the variable Buprenorphine Prescribers, which relies on the SAMHSA website listing waivered buprenorphine prescribers,[149]captures imperfect information about the number of buprenorphine prescribers actually available and taking patients. Evidence from our interviews with health plans clearly indicates that many waivered prescribers do not accept any patients or accept less than their limit, and that many who do accept patients simultaneously do not accept insurance and require payment in cash. The link between high performing health plans and this state-level variable also is attenuated by the fact that high performance on IET does not include MAT (e.g., buprenorphine) as treatment and relies instead on counseling and other non-medication services, which high performing plans in areas with few prescribers may actually rely on more heavily to compensate for the inability of their enrollees to easily access MAT. Similarly, SSA Spending--which was intended to indicate level of state support for SUDs but actually captures only a portion of resources available within states--is an imperfect proxy for market or policy realities.