Substance use issues (SUDs), together with opioid and alcohol use issues (OUDs and AUDs), are a significant public well being challenge affecting thousands and thousands of Individuals. SUDs contribute to a rising variety of deaths, with alcohol-induced and opioid overdose fatalities rising sharply in recent times, particularly in the course of the pandemic. Opioid overdose deaths grew by 63% in the course of the pandemic, to 81,051 in 2022, and alcohol-induced deaths elevated by 31%, to 51,244 in the identical yr. Regardless of this, SUDs typically go undiagnosed, unrecorded and untreated in healthcare settings.
As a dominant payer of behavioral well being companies, Medicaid generally is a lever to broaden entry to a variety of behavioral well being companies, together with therapy for SUD. This evaluation examines Medicaid claims information from 2020 to know clinically-identified charges of SUD (known as diagnoses all through the transient) in addition to therapy patterns throughout SUD companies, how therapy charges fluctuate throughout teams of Medicaid enrollees and states and spending amongst Medicaid enrollees aged 12-64 who’ve a identified SUD. Though claims information present the clearest image of the usage of Medicaid-covered companies amongst enrollees, they could exclude therapy for enrollees in some circumstances, corresponding to when companies are supplied by Indian Well being Companies, faculties or as a part of bundled fee charges (see Strategies for extra particulars).
Key takeaways embody:
- Claims information present that 7.2% of Medicaid enrollees aged 12-64 have a identified SUD. This will underestimate prevalence of SUDs as a result of screening/referral practices fluctuate and SUD diagnoses typically go unrecorded with out therapy. For instance, information from the 2020 Nationwide Survey on Drug Use and Well being, exhibits that 18% of Medicaid enrollees 12-64 have a SUD as NSDUH could seize undiagnosed SUDs. On account of decrease analysis charges in claims information, estimates of therapy charges utilizing claims information may seem increased than they are surely since they don’t account for the overall variety of enrollees with SUD.
- Practically three-quarters of these with a identified SUD in claims information used substance use therapy or supportive companies in 2020, however there are vast variations throughout service sort. For instance, therapy charges for counseling/remedy and drugs therapy have been increased than different service varieties. Remedy remedies charges are a lot increased for these identified with OUD (63%) than these with AUD (10%), though remedy therapy is really helpful for each (see Field 1).
- Enrollees who’re Black, Hispanic and Asian in addition to youth and younger adults have decrease general SUD therapy charges than different teams. Solely 4 in 10 Black enrollees with identified OUDs obtained remedy—a therapy fee considerably decrease than their White counterparts (practically 7 in 10). Youth and younger adults have decrease SUD therapy charges throughout most SUD companies in comparison with folks aged 27 to 44, notably for remedy. About 12% of youth with identified OUD obtain remedy therapy, in comparison with 63% general.
- Substantial state-level variation exists in SUD therapy general and by particular service. Remedy charges throughout states present vast variation, with as much as 50 proportion level variations in therapy charges for some companies.
- Spending for enrollees with an SUD analysis is twice as a lot as these with out a SUD (about $1,200 vs. $550 monthly on common).
Remedy is essential to addressing SUDs and lowering overdoses, deaths and different well being or social problems. Nevertheless, the charges at which Medicaid enrollees obtain therapy can fluctuate as a result of a variety of things together with the provision and capability of the behavioral well being workforce and therapy services, supplier participation in Medicaid and Medicaid protection insurance policies for SUD therapy companies. As well as, therapy charges could also be affected by the scarcity of a various and culturally competent workforce in addition to private beliefs and societal stigmas. Understanding variations in therapy charges, notably in areas or populations with decrease charges, may help inform coverage choices to deal with SUD.
What are the charges and traits of Medicaid enrollees with a identified SUD?
Total, 7.2% of Medicaid enrollees have a identified SUD in 2020 Medicaid claims information. SUDs can embody alcohol or opioid use issues, however may embody many others corresponding to marijuana, stimulant and hallucinogen use issues. As a result of OUD and AUD are essentially the most generally identified SUDs in Medicaid claims information, they usually account for over 80% of all alcohol and drug deaths, this evaluation focuses on these situations particularly in addition to SUD general (which incorporates all sorts). Medicaid claims information could underestimate the prevalence of SUDs as a result of screening/referral practices fluctuate and SUD diagnoses typically go unrecorded with out therapy. For instance, information from the 2020 Nationwide Survey on Drug Use and Well being exhibits that 18% of Medicaid enrollees 12-64 have a SUD as NSDUH could seize undiagnosed SUDs.
Medicaid enrollees who’re White, American Indian and Alaska Native (AIAN), male or older than age 26 have increased charges of identified SUD. These patterns are additionally usually constant throughout OUD and AUD, with one exception. For AUD, analysis charges are highest among the many oldest age group (45 to 64), whereas analysis charges for OUD are highest for folks aged 27 to 44 (Determine 1).
What SUD companies do Medicaid enrollees identified with SUD obtain?
Substance use therapy will be supplied in quite a lot of settings and will embody completely different therapy modalities, remedy, and supportive companies. For descriptions of those remedies and repair varieties, see Desk 1 beneath. Self-help remedies, corresponding to Alcoholics Nameless (AA) and Narcotics Nameless (NA), can also play a task in therapy however will not be included on this evaluation.
Nationally, roughly three-quarters (74%) of Medicaid enrollees with identified SUDs obtained therapy or supportive companies in 2020. Counseling/remedy, remedy and different companies (together with screening/evaluation) have the best utilization charges. A smaller share (19%) of enrollees identified with SUD obtain inpatient or residential companies, with the bottom share receiving partial hospitalization or intensive outpatient companies (8%). Supportive companies are utilized by about one in seven enrollees (Determine 2). These estimates exclude the usage of some companies in states the place sure suppliers have the choice to bundle companies or use a single code to invoice for a number of companies. Additionally they exclude companies for which suppliers didn’t straight invoice Medicaid, corresponding to these supplied by way of Indian Well being Companies, free clinics, faculties or by way of self-help teams corresponding to AA and NA.
Medicaid enrollees identified with an OUD usually have increased therapy charges than these with AUD, with the widest variation for remedy therapy. Roughly 2.9% of enrollees have a identified OUD and/or 2.6% have a identified AUD (Determine 1). Enrollees identified with OUD are likely to have increased therapy charges than these identified with AUD. Variation is most pronounced in remedy therapy—with 63% of these with identified OUD receiving remedy therapy in comparison with 10% for AUD (Determine 2). This vast distinction in therapy charges exists despite the fact that medicines for each OUD and AUD are efficient and really helpful (Field 1). Whereas charges of remedy use for AUD are low throughout payers, progress has been made in growing OUD remedy charges inside Medicaid. Nevertheless, a considerable hole stays—with about one-third of Medicaid enrollees identified with OUD not receiving remedy therapy. A number of elements could contribute to the OUD remedy therapy hole, together with problem filling buprenorphine prescriptions at pharmacies, low supplier prescribing, state and federal insurance policies in addition to various different elements.
Field 1: Remedy Remedy for SUD |
Understanding Remedy Remedies for Opioid Use Dysfunction (OUD): Remedy therapy is acknowledged as a core element of OUD therapy.
Understanding Remedy Remedies for Alcohol Use Dysfunction (AUD): Remedy therapy is acknowledged as a core element of therapy for many individuals with AUD.
|
How does use of SUD companies fluctuate by demographics and geography?
Amongst these with a identified SUD, Black, Hispanic and Asian Medicaid enrollees usually obtain SUD therapy at decrease charges than White enrollees. White enrollees are likely to have the best therapy charges throughout classes of therapy. Black enrollees with OUD are far much less prone to obtain really helpful remedy therapy (4 in 10 in comparison with practically 7 in 10 of their White counterparts). Asian enrollees have decrease charges of counseling/remedy than White enrollees. Whereas AIAN enrollees have increased remedy therapy charges for OUD (relative to many different teams), their charges for different classes, corresponding to counseling/remedy and supportive care, are usually extra variable. Numerous elements, together with low supplier cultural competency and fewer therapy choices in various communities, in addition to perceived want for therapy and private beliefs associated to searching for assist, could all play a task within the variation of therapy charges throughout racial and ethnic teams. As well as, limitations in claims information, corresponding to variations within the information high quality of race and ethnicity variables, variations in how typically SUDs are identified and recorded and potential exclusion of therapy companies supplied by Indian Well being Companies can have an effect on noticed therapy charges throughout racial and ethnic teams (see Strategies).
Youth and younger adults have decrease general SUD therapy charges than older age teams—with therapy charges notably low for OUD remedy therapy amongst youth. Total, about 65% of youth and younger grownup Medicaid enrollees use some sort of therapy or service for SUD, in comparison with 78% for the 27 to 44 age group (Determine 3). Recognized SUD is much decrease amongst youth (1.3%) and younger adults (5.4%) in comparison with these aged 27 to 44 (11.2%) (Determine 1). Probably the most notable age-related variation is for remedy therapy, with 69% of enrollees aged 27 to 44 receiving remedy for OUD, in comparison with 12% of youth (Determine 3). Remedy therapy is presently really helpful for some adolescents with OUD. Remedy therapy charges for adolescents with AUD are additionally very low, however remedy therapy shouldn’t be a part of present suggestions as a result of inadequate proof (Field 1). Women and men use SUD care at related charges throughout all sorts of therapy.
Common utilization of SUD therapy companies varies considerably throughout states. Supportive companies, medicines for OUD, and inpatient/residential companies present notably vast ranges in therapy charges. Charges for any substance use therapy amongst identified enrollees vary from 53% for the bottom state as much as 89% for the best state. The vary throughout states is especially pronounced for supportive companies and medicines for OUD (from 0.1% to 53% for supportive companies and 34% to 87% for remedy for OUD). Variation can be fairly vast for inpatient and counseling companies (Determine 4).
Though 74% of enrollees are getting some sort of therapy or service, 26% of these identified will not be getting any companies and there may be vast variation throughout states. Within the lowest therapy states, 33% to 47% of identified enrollees don’t obtain any SUD therapy or assist companies (Determine 5).
A number of states have persistently increased SUD therapy charges throughout a number of classes. Connecticut, Delaware and Vermont stand out for increased therapy charges throughout varied therapy companies. Conversely, there are states with persistently decrease therapy charges throughout classes, together with Arkansas, Georgia, Mississippi and Texas (Determine 5). Variation in therapy charges displays a mix of things, together with variations in states’ protection insurance policies, state or neighborhood efforts to broaden entry to therapy, therapy infrastructure and workforce, supplier participation with Medicaid, and variations in states’ information and the extent to which SUD diagnoses and coverings are captured within the claims information (see Strategies).
How does spending for folks with SUD evaluate to general spending?
Common Medicaid spending is twice as excessive for enrollees with a SUD analysis in contrast with different enrollees: Over $1,200 monthly and fewer than $550 monthly respectively. Notably, spending is highest for these identified with AUD, at roughly $1,400 monthly per enrollee. This sample of upper spending for people with a SUD analysis is constant throughout all age teams (Determine 6).
Why is there variation in SUD therapy charges?
This evaluation could overestimate SUD therapy charges and will underestimate sure sorts of therapy. On account of decrease analysis charges in claims information, estimates of therapy charges utilizing claims information may seem increased than they are surely, as they don’t account for the overall variety of enrollees with SUD. A number of elements could contribute to underdiagnosis, together with restricted supplier screening/referral practices, inadequate supplier coaching for SUD, diminished healthcare use for some populations, and stigma. Increasing screening past conventional settings or growing care integration may enhance identification of these in want of SUD companies. Though the information could overstate therapy charges as an entire, some particular remedies could also be lacking in circumstances the place states enable bundled funds that roll a number of sorts of SUD therapy and supportive companies right into a single code. This will end in decrease recorded utilization for some companies, notably supportive companies and can also affect counseling/remedy charges.
Amongst enrollees identified with an SUD, there may be notable variation in therapy charges for opioid use dysfunction in comparison with alcohol use dysfunction. Total OUD therapy charges usually exceed these for AUD, possible reflecting a larger coverage concentrate on addressing the opioid disaster. Variations are most acute for remedy, the place therapy charges for OUD remedy exceed AUD remedy charges by greater than 6-fold. A number of elements could assist clarify why medicines for AUD could also be much less utilized, relative to OUD, together with decrease consciousness and understanding of remedy therapy choices for AUD amongst clinicians and sufferers, uncertainties about remedy effectiveness, and challenges discovering psychosocial assist. Whereas extreme alcohol use can result in various well being points, it usually lacks the acute mortality dangers related to opioid/fentanyl use, which can scale back the urgency to provoke AUD remedy therapy. Remedy patterns could differ for different particular sorts of SUD.
Availability of substance use therapy infrastructure and workforce could play a task in variation in therapy charges for sure populations. For instance, youth and younger adults obtain SUD therapy at decrease charges, probably as a result of a scarcity of specialised services for this inhabitants. Some states are addressing therapy wants by including protection for companies in non-traditional settings, corresponding to faculties, although it isn’t clear whether or not these companies will seem in Medicaid claims information. Decrease therapy charges for some racial and ethnic teams could contribute to increased overdose loss of life charges. Components corresponding to low supplier cultural competency in care, lack of range within the behavioral well being workforce, private beliefs and societal stigmas, perceived want for therapy and restricted therapy infrastructure or fewer therapy choices in various communities could all play a task.
Substantial state-level variation in therapy charges exist and will mirror variations in coated companies, workforce, infrastructure, state traits and the character of their Medicaid fee methods and information. States expanded protection for SUD companies in recent times. Entry to companies not solely relies on Medicaid protection of companies and the provision of services and beds, but additionally on the presence of a behavioral well being workforce to maintain services operational and to offer therapy companies. Different state Medicaid efforts which have centered on addressing the opioid epidemic and different SUDs embody lowering prior authorization obstacles for buprenorphine, increasing telehealth entry, including OTC Narcan to formularies and exploring pre-release Medicaid protection for incarcerated populations. There have been federal efforts to broaden entry to SUD therapy and the President’s funds contains various provisions to additional strengthen behavioral well being, a few of which embody increasing funding for the State Opioid Response grant program, increasing behavioral well being companies in faculties and strengthening the behavioral well being workforce.
Medicaid unwinding could result in loss or interruptions in protection for individuals who rely on Medicaid for SUD therapy. Protection interruptions may disrupt enrollee entry to obligatory therapy and enhance the danger of overdose or problems. The current resumption of Medicaid renewals following a three-year pandemic halt, often called the ‘Medicaid unwinding’, has led to thousands and thousands of people dropping Medicaid protection. Many individuals who lose Medicaid have different insurance coverage choices. Nevertheless, for individuals who depend on Medicaid to cowl SUD therapy, the lack of Medicaid protection may disrupt their entry to ongoing SUD therapy. Such a loss could disrupt therapy and enhance overdose or complication dangers.
This work was supported partly by Properly Being Belief. KFF maintains full editorial management over all of its coverage evaluation, polling, and journalism actions.
Strategies |
Medicaid Claims Information: This evaluation used the 2020 T-MSIS Analysis Identifiable Recordsdata together with the inpatient (IP), long-term care (LT), different companies (OT), and pharmacy (RX) claims information merged with the demographic-eligibility (DE) information from the Persistent Situation Warehouse (CCW).
Figuring out SUD Diagnoses: This evaluation recognized SUD diagnoses utilizing the Behavioral Well being Service Algorithm (BHSA) reference codes supplied by The City Institute. The BHSA identifies SUD with ICD-9 and ICD-10 analysis codes, process codes, service codes, and Nationwide Drug Codes (NDCs). “Any SUD” is a complete class that features SUDs that contain alcohol, opioids, marijuana, inhalants, sedatives, hallucinogens, psychostimulants, and/or substances labeled as “different” or “unspecified” in claims information. This evaluation additionally individually examined alcohol and opioid use issues. See: Victoria Lynch, Lisa Clemans-Cope, Paul Johnson, Marni Epstein, Doug Wissoker, and Emma Winiski. Behavioral Well being Companies Algorithm. Model 3. Washington, DC: City Institute, 2022. Figuring out SUD Utilization and Medicaid Remedy Companies Classes of Care: The City Institute’s BHSA additionally recognized use of the next SUD therapy service classes:
Spending: Spending information contains fee-for-service spending in addition to per member monthly funds to Medicaid managed care. Enrollee Inclusion Standards: This evaluation contains enrollees ages 12 to 64 who had full Medicaid or CHIP protection for not less than one month. Remedy charges have been related if the pattern was restricted to enrollees with not less than six months of full protection. State Inclusion Standards: To evaluate the usability of states’ information, the evaluation examined high quality assessments from the DQ Atlas for claims quantity and managed care encounters and in contrast the proportion of individuals with SUD to estimates from the 2021 Nationwide Survey on Drug Use and Well being (NSDUH) state estimates (because of the unavailability of 2020 NSDUH information).The evaluation excluded any states that had each a “Excessive Concern/ Unusable” DQ Atlas evaluation and a distinction between the NSDUH and claims-based estimates larger than 10.9 proportion factors (which corresponded to the 75th percentile of the distribution of variations). Washington D.C. was excluded based mostly on these standards, leaving 50 states within the evaluation. For reporting by race/ethnicity, the evaluation excluded states with “Excessive Concern/Unusable” DQ Atlas assessments. Among the many states in the principle evaluation, 19 have been excluded (AL, AZ, AR, CO, CT, HI, IA, KS, LA, MD, MA, MO, NY, OR, RI, SC, TN, UT, and WY). This left 31 states for reporting by race/ethnicity (Determine 3). Limitations of Claims Information:
Nationwide Survey on Drug Use and Well being. The Nationwide Survey of Drug Use and Well being (NSDUH) asks nationally illustration pattern of respondents 12 and older about substance use and signs of substance use issues. Those that exceed sure thresholds are categorised as having a SUD. This evaluation makes use of the 2020 NSDUH public use file and contains Medicaid enrollees between the ages of 12 and 64 who met DSM-V standards for a SUD involving alcohol or illicit medication. Illicit medication embody marijuana, cocaine, heroin, hallucinogens, inhalants, methamphetamine and the misuse of prescription psychotherapeutic medication (i.e., ache relievers, tranquilizers, stimulants, and sedatives). City Institute’s BHSA contains the identical substances in addition to codes for “different” or “unspecified” substances. NSDUH captures individuals who could not have a clinically recognized or identified case, so charges of SUD are increased than claims information throughout demographic teams; nonetheless, NSDUH should still underestimate SUD prevalence. NSDUH solely collects information from folks with an handle–excluding those that are unhoused, institutionalized, or incarcerated–which is related as a result of these populations could have increased charges of substance use issues. |
Appendix