Examining Substance Use Disorder Treatment Demand and Provider Capacity in a Changing Health Care System: Final Report. I. INTRODUCTION


A. Purpose of Report

Despite federal policies enacted within the last decade aimed at promoting insurance coverage for substance use disorders (SUDs), the exiting SUD treatment workforce may be insufficient to accommodate the potential increase in demand for care and other factors may be contributing to stagnant treatment utilization rates. The Affordable Care Act (ACA) specifically required subsidized marketplace insurance plans, individual and small group market plans, and Medicaid expansion programs to cover SUD treatment as an essential health benefit. Two years before passage of the ACA, the 2008 Mental Health Parity and Addiction Equity Act (MHPAEA) began requiring private insurance plans that included behavioral health benefits and were offered through large group insurers to cover those services on a par with medical/surgical care (Humphreys and Frank 2014; Beronio et al. 2014).

Providing insurance coverage for SUD treatment is intended to reduce financial barriers to treatment use and thereby increase the proportion of individuals with SUD treatment needs who seek and receive evidence-based care. However, the existing SUD treatment workforce may be insufficient to accommodate an increase in demand for care and other factors may be limiting treatment utilization. To address this concern, in September 2014, the U.S. Department of Health and Human Services (HHS) Office of the Assistant Secretary for Planning and Evaluation contracted with Mathematica Policy Research to assess: (1) the current demand for SUD treatment; (2) how demand will change as more people obtain insurance coverage for this treatment; (3) the current state of capacity in the SUD treatment field; and (4) the degree to which treatment providers are prepared for integration into the broader health care system.

A previous report from this study (Bouchery et al. 2015) reviewed and analyzed the available literature and data on SUD prevalence, treatment, and workforce capacity, and incorporated information obtained through expert interviews. In the current report, we supplement the findings from the previous report with analyses of newly collected survey data on the size and characteristics of the workforce. We also reassess supply and demand trends described in the previous report, incorporating newly available data for the period following the insurance expansions that began in 2014. The following research questions guided our analyses:

1. Demand-Related Questions

  • How many people are receiving SUD treatment services, and what services are they receiving?

  • How does service receipt vary geographically?

  • What is the relationship between prevalence of SUDs and demand for care? How does this relationship vary geographically?

  • What evidence exists about how increases in Medicaid enrollment have impacted demand?

2. Supply-Related Questions

  • What are the professions and SUD treatment credentials of the current workforce?

  • What is the current capacity of service providers to supply SUD treatment services? How does provider capacity differ across geographic areas? What disparities in care access are evident (for example, by region or subpopulation)? How does provider capacity differ in relation to various services, such as inpatient, residential, intensive outpatient, outpatient, and pharmacotherapy?

  • What is the current capacity of SUD treatment organizations to participate in efforts to integrate SUD treatment within the broader health care system? To what degree are SUD treatment providers used to billing Medicaid?

  • How have wages for SUD treatment staff changed over the last decade?

B. Report Methods

We conducted the study in two phases:

  • In Phase 1, from October 2014 through December 2015, we: (1) assessed available data sources to answer the research questions and analyzed relevant data from these sources; (2) reviewed and summarized findings from the existing professional literature that addressed the questions; (3) interviewed selected experts; and (4) developed supplemental questions regarding the workforce to be fielded with an existing survey of SUD treatment facilities in 2016.

  • In Phase 2, from September 2015 through November 2017: (1) the HHS Substance Abuse and Mental Health Services Administration (SAMHSA) fielded the SUD workforce survey questions we developed, and we analyzed the results; and (2) we updated the analyses we conducted in the first phase to include newly released data so as to identify more recent trends.

Below, we briefly summarize the methods we used in conducting the study.

1. Review and Analysis of Existing Data Sources

We reviewed pre-existing sources of data regarding SUD treatment supply and demand, and identified the strengths and limitations of each. Based on this analysis, we determined which data sources were most relevant for describing the current state of and relevant trends in the supply of and demand for SUD treatment services. We obtained these data, analyzed them, and presented the results in our previous report. For the current report, we extended the analyses of selected trends for which more recent data have since become available. Appendix A provides a brief overview of the data sources analyzed in this study.

2. Literature Review

Using a defined set of key words, we searched the Cumulative Index to Nursing and Allied Health Literature, PsycINFO, Scopus, and PubMed databases for literature published from 2005 through November 2014 on the following topic areas:

  • Current demand for SUD treatment services.

  • Trends and policies impacting demand over the next decade.

  • Previous efforts to estimate the size and composition of the SUD workforce.

  • Recruiting and developing the workforce.

We also used Google to search for important studies in the gray literature. We reviewed the publication information and abstracts retrieved for relevance to our study and strength of the methodology used. We then obtained the studies most likely to provide evidence related to the four topic areas of interest and extracted relevant information from each.

3. Expert Interviews

In May and June of 2015, we interviewed three SUD workforce experts. First, we interviewed the executive director of the International Certification and Reciprocity Consortium (IC&RC), which develops standards and examinations that its local boards across the country use for credentialing and licensing. The director responded to our interview questions orally and provided written responses to the questions in our interview guide from local board staff in Louisiana, Minnesota, North Carolina, and Ohio. Next, we interviewed the executive director of the National Association for Alcoholism and Drug Abuse Counselors (NAADAC), an association for professionals in the SUD treatment workforce that also develops examinations for certifications. We conducted the third interview with the senior vice president of public policy and practice improvement for the National Council for Behavioral Health, an association of behavioral health provider organizations.

The interviews with the IC&RC and NAADAC representatives addressed trends in addiction provider certification and training programs; state requirements for licensing and certification; and recent changes in the workforce, including those associated with the ACA and MHPAEA. The interview with the National Council for Behavioral Health representative addressed the following topics:

  • Providers' experiences related to implementation of the ACA and MHPAEA.

  • How providers have adapted to the availability of expanded Medicaid and private insurance coverage for SUD treatment.

  • Barriers providers have identified related to supporting patient treatment through insurance coverage.

  • The most pressing concerns for providers related to training programs for SUD treatment professionals, recruitment and hiring of qualified staff, and retention of existing staff.

  • Those state-level differences in licensing/credentialing policies or professional certification requirements that have an important impact on the availability of SUD treatment programs or program staffing patterns.

The experts did not have data available to support responses to most questions and thus could provide only anecdotal information. They also were not able to address all topics identified. IC&RC and NAADAC representatives indicated that state board representatives might have information to address particular questions, but this information typically is not passed on to the national organization.

4. National Survey of Substance Abuse Treatment Services (N-SSATS) 2016 Supplemental Workforce Questions

Because no data had been collected on the size and composition of the SUD workforce since the late 1990s, we developed supplemental questions about them that were added to the 2016 N-SSATS, which surveys all specialty SUD treatment facilities in the United States and its territories. The supplemental questions asked facilities to identify, by profession, the total number of staff, staff hours worked in a week, and the number of paid and non-paid staff certified in addiction treatment.7