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


Policymakers at all levels of government have targeted increasing SUD treatment use to address escalating drug overdose deaths related to the opioid epidemic and improve societal welfare. Meanwhile, rates of SUD treatment use generally have been constant for more than a decade despite the substantial recent increase in insurance coverage for SUD treatment. Individuals with SUD treatment needs overwhelmingly indicate that they do not feel a need for treatment and, even among the small minority who believe that they might benefit from treatment, most make no effort to obtain it. Thus, expanding treatment use will require a multifaceted approach including increasing public awareness of treatment effectiveness, reducing stigma associated with SUD treatment, addressing financial barriers, and increasing primary care physicians' role in screening, treatment and referral.

On the supply side, low wage rates for SUD treatment professionals are associated with high turnover and difficulty in hiring qualified staff. Individuals trained to provide SUD treatment quickly move on to other professions that offer better working conditions, wages, and benefits (Hyde 2013; Ryan et al. 2012; Bukach 2017). There is also concern that low treatment reimbursement rates and restrictions on SUD treatment coverage under Medicaid may be a barrier to expanding treatment in some states (Dickson 2015).

Overall, the role of Medicaid in funding SUD treatment services has expanded since 2014 although many of the individuals who gained Medicaid coverage would have received SUD treatment through another funding source such as state and local funding or federal block grants. In parallel to this shift in funding source there has been a shift from care provision in publicly operated facilities to increased use of privately operated facilities. There is an opportunity for policymakers to redirect the public funding and resources to activities encouraging expanded treatment use and providing a continuum of care that addresses the chronic nature of SUDs. Likewise state Medicaid programs have the potential to play an important role in transforming the SUD treatment system and HHS Centers for Medicare and Medicaid Services (CMS) is taking an active role encouraging states to make reforms. CMS is conducting an Innovation Accelerator Program (IAP) to support state efforts to expand SUD treatment under Medicaid. The IAP supports efforts to improve care quality and continuity, enhance performance monitoring capacity, identify beneficiaries in need of treatment, develop a continuum of care that addresses the variety treatment needs and the chronic nature of SUDs, and target reimbursement models to incentivize better outcomes (CMS 2017). In addition, CMS has been working with states to improve access to and quality of SUD treatment through Medicaid Section 1115 demonstrations (CMS 2017b).

The impact of a number of recent federal efforts to increase SUD treatment use and the quality of SUD treatment services is not fully captured in the data available for this study. The initiatives include the CMS IAP program as well as several SAMHSA grant programs intended to expand access to SUD treatment (McCance-Katz et al. 2017). The Opioid State Targeted Response grants provided $485 million to states and United States territories in fiscal year 2017 primarily to expand treatment, recovery support and prevention activities. The Medication-Assisted Treatment for Prescription Drug and Opioid Addiction program expands pharmacotherapy access by providing grants to states with the highest rates of treatment admissions for opioid addiction. There are also a number of federally-funded efforts to expand access to SUD screening and treatment in primary care settings and rural areas including integrating SUD treatment into community mental health centers, use of telemedicine, efforts to educate primary care providers on addiction risks and treatment, partnerships between primary care and specialty providers, and expansion of buprenorphine waivered primary care providers and the number of patients that can be treated under each waiver. Future years of data should be monitored to assess the impact of these initiatives.