The literature review and analysis of existing data sources identified many gaps in current knowledge. These gaps are summarized in the first section below. In the final section, we identify the work we will complete in the second phase of this project.
A. Gaps in Current Knowledge
Many gaps in current knowledge were identified under this study, including the following:
Current Demand for SUD Treatment Services. Overall, the literature on factors influencing demand for treatment is quite limited. Much of the available literature is based on survey responses or observational assessments of perceived barriers. Several of the studies base their analyses of the relationship between treatment use and insurance coverage on cross-sectional data. The findings of these studies may be confounded by unobserved differences between populations with different insurance types, such as differences in severity of condition or employment. We did not identify any studies using an experimental design to examine this relationship. Improving the methodological approach to such studies would provide policymakers with more definitive information on how individuals may respond to improved access to insurance coverage for SUD treatment services under various circumstances.
Trends and Policies Impacting Demand. Efforts to project the impact of policy changes are inherently limited by lack of information on how individuals will respond to a new situation; therefore, assessing the impacts of recent policy changes on treatment use will require monitoring over time. At the time of this review, no studies were yet available quantifying the impact of the ACA on treatment use. Information on how the recent legalization of marijuana use in some states will affect treatment use is also limited. In addition, despite much interest in care integration, the degree to which such models will be implemented is unknown. Monitoring trends in dissemination of care integration and developing estimates of their impact on SUD treatment receipt would provide a foundation for understanding how these approaches may impact demand.
Previous Efforts to Estimate the Size and Composition of the SUD Workforce. The most recent data on the size and professional composition of the workforce is from the late 1990s. Updated estimates are needed, as changes in treatment approaches, such as expanded use of MAT (which requires increased medical staffing), may have resulted in significant changes in the composition of the workforce since that time. Also, studies of the size and composition of the workforce have focused on the national level. More detailed information on variations in the workforce by state, urban/rural location, facility type, size, and ownership would provide data for understanding disparities in facility staffing. Similarly, data on facility organization and staffing patterns are limited. Information on alternative staffing models and the associated quality and efficiency of care provided would help guide initiatives to create national staffing norms.
Recruiting and Developing the Workforce. Although some literature on state-level credentialing and licensing requirements exists, we did not find any studies analyzing the relationship between these requirements and the size and composition of the SUD workforce in each state. There is limited information on the pipeline for SUD treatment professions. The limited literature available suggests that professionals with a bachelor's degree or higher come from a variety of fields and obtain training specific to SUD treatment outside the requirements for their degree. Additional research on typical career paths is needed and might inform development of more streamlined training. Although the literature includes many suggested approaches for increasing the supply of SUD professionals, no information documents the potential impact of implementing the suggested strategies. Although clinical directors and credentialing experts expressed concern about training adequacy, few analyses have documented how variation in the training and experience of SUD treatment professionals impacts care quality or assessed how training might be improved.
B. Next Steps
The current report includes interim findings from Phase I of this project. Phase II of the current study will be conducted from September 2015 through February 2018 and will include the following tasks:
Workforce Survey 2016. Analysis of supplemental workforce questions included in the N-SSATS 2016 survey. These data will identify the number of paid and unpaid staff in the specialty SUD treatment facility workforce, by profession.
Supplemental Literature Review. We will analyze additional literature that becomes available between June 2015 and September 2017 and provides key evidence on the impact of the ACA and trends in SUD treatment supply and demand in post-ACA implementation.
Final Report. The current initial findings report will be updated to incorporate the findings from the 2016 workforce survey and the supplemental literature review.