Initiation and Receipt of Medication for Opioid Use Disorder Among Adolescents and Young Adults in 4 State Medicaid Programs in 2018: Improving Medicaid Quality Metrics.

BACKGROUND: Medications for opioid use disorder (MOUD) in youth can reduce harms but many youths do not receive MOUD. Improving quality metrics of MOUD among youth can advance interventions for youth with opioid use disorder (OUD). METHODS: We relied on 2018 Medicaid claims data from California, Colorado, Massachusetts, and New Mexico. We calculated the percentage of youth with OUD included in the quality metric for initiation, and the percentage who initiated by state. We also calculated the percentage excluded from the quality metric for initiation because they have an existing episode of OUD care and their MOUD receipt. We compared the characteristics of those who initiated/received MOUD to those who did not and compared state estimates after adjusting for age and health conditions. RESULTS: Estimates of initiation exclude about half of the youth with OUD because they were in an existing episode of OUD care and could not be observed initiating. Among youth in a new episode of OUD care, only about 1 in 4 initiated and state estimates varied from 18.9% to 40.1%. Among youth with an existing episode of OUD care, more than half received MOUD and state estimates ranged from 35.2% to 71.3%. Youth who initiated MOUD or received MOUD with an existing OUD had more severe OUD but fewer co-occurring substance use disorders or mental or physical health diagnoses. After adjusting for age and health conditions, MOUD still varied substantially across states. CONCLUSIONS: Most youth with a new OUD diagnosis do not initiate MOUD but more than half of the youth in an existing OUD diagnosis receive MOUD. MOUD quality metrics that are disaggregated, adjusted, and inclusive of youth in an existing episode of care provide additional insight into opportunities to better support youth who might choose MOUD. State differences should be further studied for insight into policies that may affect MOUD.

Estimates of Medicaid and Non-Medicaid Net Prices of Top-Selling Brand-name Drugs Incorporating Best Price Rebates, 2015 to 2019.

Importance: The US spends far more on brand-name prescription drugs than other comparable countries. However, studies of prescription drug spending in the US are often limited because there can be substantial differences in the confidential rebates that drug manufacturers pay to Medicaid vs other payers. Objectives: To demonstrate an approach for improved estimation of Medicaid rebates through case studies of 18 top-selling drugs to better understand trends in net Medicaid and non-Medicaid spending and prices for brand-name drugs. Design, Settings, and Participants: This was a cross-sectional study of US pricing data from 2015 to 2019 derived from Medicaid State Drug Utilization data SSR Health, Medi-Span, the Federal Supply Schedule, and IQVIA. Pricing data for 18 top-selling brand-name drugs measured consistently in both SSR Health, which captures US sales reported by publicly traded companies, and IQVIA's top US prescription drugs by nondiscounted spending in 2015 to 2019. Data were accessed and analyzed from January 2019 to June 2021. Main Outcomes and Measures: Gross and net Medicaid and non-Medicaid drug spending for the sample of 18 drugs and prices corresponding to a 30-day supply of medication. Results: Medicaid aggregate gross spending for the 18 drugs in the sample increased 173%, from $3.6 billion in 2015 to $9.9 billion in 2019, and estimated net spending after discounts increased by 119%, from $1.4 billion to $3.0 billion. Medicaid inflation-linked rebates reduced average gross price per 30-day supply by an estimated 43% in 2019, and up to 67% for individual drugs. In addition to the basic rebate, the best price provision reduced the average gross price per 30-day supply by an estimated 3% in 2019 and up to 54% for individual drugs. Between 2015 and 2019 across all study drugs, estimated average non-Medicaid net 30-day prices were between 1.9 and 2.6 times higher than Medicaid net prices. Excluding adalimumab-a spending anomaly because of the entry of a new high-cost formulation-net prices weighted by average gross spending decreased annually by 1% from 2015 through 2019 for Medicaid, while increasing by 2% for non-Medicaid payers. Conclusions and Relevance: In this cross-sectional study of 18 top-selling brand-name drugs, excluding 1 anomaly, Medicaid average net prices declined from 2015 to 2019. Simultaneously, for non-Medicaid payers, net price increased more than previously published marketwide growth rates, raising the importance of restraining drug price growth in non-Medicaid markets. Rigorous and transparent methods to estimate Medicaid discounts are imperative to understand patterns in Medicaid and non-Medicaid prices and develop policies that better align drug prices with clinical benefits.

Medicaid professional fees for treatment of opioid use disorder varied widely across states and were substantially below fees paid by medicare in 2021.

BACKGROUND: As Medicaid is the largest payer for opioid use disorder (OUD) treatment services in the United States, information about Medicaid provider reimbursement is critical, and Medicaid payment policies influence the structure of OUD treatment services for everyone with OUD treatment needs. METHODS: We collected Medicaid professional fees for OUD treatment and related services for the District of Columbia and fifty state Medicaid programs and the Medicare program in 2021. We create three fee indexes related to OUD treatment, with an emphasis on services related to first-line medication treatments in outpatient settings. We then create Medicaid fee indexes and Medicaid-to-Medicare fee indexes. RESULTS: Weekly Medicaid fee bundles for methadone treatment at OTPs in 2021 varied widely, more than 4-fold across states. The Medicaid-to-Medicare fee index shows that the national average Medicaid fee bundle was 56 percent of Medicare fees for regular methadone treatment at OTPs in 2021. For services related to OUD treatment, Medicaid fees varied up to 5-fold and larger across the components of each of the four services, and Medicaid fees were low relative to Medicare for almost all state services examined. The Medicaid-to-Medicare fee index was 64 percent of Medicare fees in 2021, ranging from 52 percent for evaluation & management to 76 percent for toxicology testing. CONCLUSIONS: There appears to be little justification for such large variation in Medicaid fees across states. In addition, the generally low fees in Medicaid persist despite recent efforts to increase access to opioid use disorder treatment for Medicaid enrollees, and have important implications for access to life-saving treatment during the current opioid overdose crisis.

Diagnosis and treatment of substance use disorder among pregnant women in three state Medicaid programs from 2013 to 2016.

Substance use disorder (SUD) during pregnancy increases risks of adverse outcomes for mothers and children. Because Medicaid covers about half of all births and maternal SUD is a costly problem, describing the timing of enrollment and health care that Medicaid-enrolled pregnant women with SUDs receive is critical to understanding gaps in the timeliness and specificity of SUD diagnosis and treatment for pregnant women with SUDs. We used linked maternal and infant Medicaid claims and enrollment data and infant birth records from three states (n=72,086 mother-infant dyads) to estimate the share of sample women diagnosed with a specified SUD (e.g., opioid use disorder) before or during the birth month, with a specified SUD after the birth month, and with only an unspecified SUD diagnosed (e.g., drug use disorder complicating pregnancy). We also examined the timing of first observed Medicaid enrollment, SUD diagnosis and treatment, and maternal and infant costs. In the 24 months surrounding birth, 3.6% of women had a specified SUD diagnosis first observed before or during the birth month, 1.7% had a specified SUD diagnosis first observed after the birth month, and 6.0% had an SUD diagnosis that was not specified. Most women with a specified SUD diagnosis were enrolled in Medicaid before or early in pregnancy and initiated prenatal care in the first or second trimester, yet nearly one-third of these women received their specified SUD diagnosis after the birth month. Less than two-thirds of women with a specified SUD diagnosis received any SUD treatment during the study period (59.9% among those identified before or during the birth month and 63.1% among those observed after the birth month), and women with an unspecified SUD were about half as likely to get treatment (28.6%). Among treated women, more than two-thirds had the first observed treatment in the same month as their first observed SUD diagnosis. Findings point to a critical need for interventions as well as substantial opportunities to improve the identification of substance use-related needs and provision of treatment among women who birth in Medicaid. Changes in Medicaid and other public policy to reduce disincentives for pregnant and parenting women to report substance use during medical visits and to increase providers' abilities and motivation to equitably screen for as well as treat women with SUDs before, during, and after pregnancy could improve outcomes for mothers and their children. Improvements in SUD diagnosis would also improve prevalence estimates of specific types of SUD, which could contribute to better Medicaid policies aimed at prevention and treatment.

Neonatal abstinence syndrome management in California birth hospitals: results of a statewide survey.

OBJECTIVE: Assess management of neonatal abstinence syndrome (NAS) in California hospitals to identify potential opportunities to expand the use of best practices. STUDY DESIGN: We fielded an internet-based survey of 37 questions to medical directors or nurse managers at 145 birth hospitals in California. RESULTS: Seventy-five participants (52%) responded. Most respondents reported having at least one written protocol for managing NAS, but gaps included protocols for pharmacologic management. Newer tools for assessing NAS severity were not commonly used. About half reported usually or always using nonpharmacologic strategies; there is scope for increasing breastfeeding when recommended, skin-to-skin care, and rooming-in. CONCLUSIONS: We found systematic gaps in care for infants with NAS in a sample of California birth hospitals, as well as opportunities to spread best practices. Adoption of new approaches will vary across hospitals. A concerted statewide effort to facilitate such implementation has strong potential to increase access to evidence-based treatment for infants and mothers.

Opioid and Substance Use Disorder and Receipt of Treatment Among Parents Living With Children in the United States, 2015-2017.

PURPOSE: Little is known about the prevalence of opioid use disorder (OUD) among parents who are living with children and their receipt of treatment, which could reduce the harmful effects of OUD on families. METHODS: We used 2015-2017 cross-sectional national survey data to estimate prevalence and treatment of opioid use disorder and other substance use disorders (SUD) among parents living with children. RESULTS: An estimated 623,000 parents with opioid use disorder are living with children, and less than one-third of these parents received treatment for illicit drug or alcohol use at a specialty facility or doctor's office. Treatment rates were even lower among the more than 4,000,000 parents estimated to have other SUDs. CONCLUSION: Many parents in both groups have concurrent mental health issues, including suicidal thoughts and behavior. Primary care practices can play a critical role in screening and facilitating treatment initiation.

Pregnant women with opioid use disorder and their infants in three state Medicaid programs in 2013-2016.

BACKGROUND: Maternal opioid use disorder (OUD) has serious consequences for maternal and infant health. Analysis of Medicaid enrollee data is critical, since Medicaid bears a disproportionate share of costs. METHODS: This study analyzes linked maternal and infant Medicaid claims data and infant birth records in three states in the year before and after a delivery in 2014-2015 (2013-2016) examining health, health care use, treatment, and neonatal outcomes. Diagnosis and procedure codes identify OUD and other substance use disorders (SUDs). RESULTS: In the year before and after delivery, 2.2 percent of the sample had an OUD diagnosis, and 5.9 percent had a SUD diagnosis other than OUD. Of the women with OUD, 72.8% had treatment for a SUD in the year before and after delivery, but most had none in an average enrolled month, and only 8.8% received any methadone treatment in a given month. Pregnant women with OUD had delayed and lower rates of prenatal care compared to women with other substance use disorders (SUDs). Infants of mothers with OUD did not differ from infants of mothers with other SUDs in rate of preterm or low birth weight but had higher NICU admission rates and longer birth hospitalizations. Health care costs for women with an OUD were higher than those with other SUDs. CONCLUSIONS: There is an urgent need for comprehensive, evidence-based OUD treatment integrated with maternity care. To fill critical gaps in care, workforce and infrastructure innovations can facilitate delivery of preventive and treatment services coordinated across settings.

Experiences of three states implementing the Medicaid health home model to address opioid use disorder-Case studies in Maryland, Rhode Island, and Vermont.

PURPOSE: The United States is facing an unprecedented opioid epidemic. The Affordable Care Act (ACA) included several provisions designed to increase care coordination in state Medicaid programs and improve outcomes for those with chronic conditions, including substance use disorders. Three states-Maryland, Rhode Island, and Vermont - adopted the ACA's optional Medicaid health home model for individuals with opioid use disorder. The model coordinates opioid use disorder treatment that features opioid agonist therapy provided at opioid treatment programs (OTPs) and Office-based Opioid Treatment (OBOT) with medical and behavioral health care and other services, including those addressing social determinants of health. This study examines state approaches to opioid health homes (OHH) and uses a retrospective analysis to identify facilitators and barriers to the program's implementation from the perspectives of multiple stakeholders. METHODS: We conducted 28 semi-structured discussions with 70 discussants across the three states, including representatives from state agencies, OHH providers (OTPs and OBOTs), Medicaid health plans, and provider associations. Discussions were recorded, transcribed, and analyzed using NVivo. In addition, we reviewed state health home applications, policies, regulatory guidance, reporting, and other available OHH materials. We adapted the Exploration, Preparation, Implementation, and Sustainment (EPIS) model as a guiding framework to examine the collected data, helping us to identify key factors affecting each stage of the OHH implementation. RESULTS: Overall, discussants reported that the OHH model was implemented successfully and was responsible for substantial improvements in patient care. Contextual factors at both the state level (e.g., legislation, funding, state leadership, program design) and provider level (OHH provider characteristics, leadership, adaptability) affected each stage of implementation of the OHH model. States took a variety of approaches in designing and implementing the model, with facilitators related to gathering stakeholder input, receiving guidance and technical assistance, and tailoring program design to build on the state's existing care coordination initiatives and provider infrastructure. The OHH model constituted a substantial change for almost all OHH providers in the study, who reported that facilitators to implementation included having goals and workplace culture that were compatible with the OHH model, and having technical support from the state or non-governmental organizations. Some of the main barriers to implementation reported by OHH providers include shortages of primary care providers, dentists, and other providers willing to accept referrals of patients with opioid use disorder; limited community resources to address social determinants of health; challenges related to state-specific program design, such as staffing requirements and reimbursement methodology; care coordination limitations due to confidentiality restrictions and technological barriers; and internal capacity of providers to adopt the new model of care. CONCLUSIONS: The OHH model appears to have the potential to effectively address the complex needs of individuals with opioid use disorder by providing whole-person care that integrates medical care, behavioral health, and social services and supports. The experiences of Maryland, Rhode Island, and Vermont can guide development and implementation of similar OHH initiatives in other states.

How Well Is CHIP Addressing Health Care Access and Affordability for Children?

OBJECTIVE: We examine how access to care and care experiences under the Children's Health Insurance Program (CHIP) compared to private coverage and being uninsured in 10 states. METHODS: We report on findings from a 2012 survey of CHIP enrollees in 10 states. We examined a range of health care access and use measures among CHIP enrollees. Comparisons of the experiences of established CHIP enrollees to the experiences of uninsured and privately insured children were used to estimate differences in children's health care. RESULTS: Children with CHIP coverage had substantially better access to care across a range of outcomes, other things being equal, particularly compared to those with no coverage. Compared to being uninsured, CHIP enrollees were more likely to have specialty and mental health visits and to receive prescription drugs; and their parents were much more likely to feel confident in meeting the child's health care needs and were less likely to have trouble finding providers. CHIP enrollees were less likely to have unmet needs, but 1 in 4 had at least 1 unmet need. Compared to being privately insured, CHIP enrollees had generally similar health care use and unmet needs. Additionally, CHIP enrollees had lower financial burden related to their health care needs. The findings were generally robust with respect to alternative specifications and subgroup analyses, and they corroborated findings of previous studies. CONCLUSIONS: Enrolling more of the uninsured children who are eligible for CHIP improved their access to a range of care, including specialty and mental health services, and reduced the financial burden of meeting their health care needs; however, we found room for improvement in CHIP enrollees' access to care.

How Well Is CHIP Addressing Oral Health Care Needs and Access for Children?

OBJECTIVE: We examine how access to and use of oral and dental care under the Children's Health Insurance Program (CHIP) compared to private coverage and being uninsured in 10 states. METHODS: We report on findings drawn from a 2012 survey of CHIP enrollees in 10 states. We examined a range of parent-reported dental care access and use measures among CHIP enrollees. Comparisons of the experiences of established CHIP enrollees to the experiences of newly enrolling children who had been uninsured or privately insured were used to estimate the impacts of CHIP on children's oral health and dental care. RESULTS: Most children enrolled in CHIP had a usual source of dental care and had received a dental checkup or cleaning in the past year, and most over age 6 had had sealants placed on their molars. In addition, parents of most CHIP enrollees were aware that CHIP covered dental benefits, and most reported not having trouble finding a dentist to see their child. Even so, 12% of CHIP enrollees had unmet dental care needs. Compared to being uninsured, CHIP enrollees did better across nearly all oral health measures. Compared to being privately insured, CHIP enrollees were more likely to have dental benefits, to have a usual source of dental care, and to have had a dental checkup/cleaning, but they were more likely to have trouble finding a dentist and less likely to say that their child's teeth were in excellent/very good condition. CONCLUSIONS: Enrolling eligible uninsured children in CHIP led to improvements in their access to preventive dental care, as well as reductions in their unmet dental care needs, yet the CHIP program has more work to do to address the oral health problems of children.

Trade-offs between public and private coverage for low-income children have implications for future policy debates.

Much of the discussion around the Affordable Care Act has focused on likely changes in coverage and access to care for adults. However, the law also alters coverage options for many low-income children. We used data from the new Health Reform Monitoring Survey Child Supplement to examine access to care and related outcomes for low-income publicly and privately insured children. We found that over 90 percent of low-income insured children had a usual source of care and had parents who were confident that their children could get the health care they need, regardless of their type of coverage. However, on a variety of cost-related measures, including difficulty paying the child's medical bills, out-of-pocket expenses, and satisfaction with health insurance premiums and copayments, children with Medicaid or the Children's Health Insurance Program (CHIP) fared better than those with employer-sponsored insurance. These results have implications for debates about the future of CHIP and other policies that affect public and private coverage options available to children and families.

The health reform monitoring survey: addressing data gaps to provide timely insights into the affordable care act.

The Health Reform Monitoring Survey (HRMS) was launched in 2013 as a mechanism to obtain timely information on the Affordable Care Act (ACA) during the period before federal government survey data for 2013 and 2014 will be available. Based on a nationally representative, probability-based Internet panel, the HRMS provides quarterly data for approximately 7,400 nonelderly adults and 2,400 children on insurance coverage, access to health care, and health care affordability, along with special topics of relevance to current policy and program issues in each quarter. For example, HRMS data from summer 2013 show that more than 60 percent of those targeted by the health insurance exchanges struggle with understanding key health insurance concepts. This raises concerns about some people's ability to evaluate trade-offs when choosing health insurance plans. Assisting people as they attempt to enroll in health coverage will require targeted education efforts and staff to support those with low health insurance literacy.

The expansion of Medicaid coverage under the ACA: implications for health care access, use, and spending for vulnerable low-income adults.

The expansion of Medicaid coverage under the Affordable Care Act offers the potential for significant increases in health care access, use, and spending for vulnerable nonelderly adults who are uninsured. Using pooled data from the Medical Expenditure Panel Survey, this study estimates the potential effects of Medicaid, controlling for individual and local community characteristics. Our findings project significant gains in health care access and use for uninsured adults who enroll in Medicaid coverage and have chronic health conditions and mental health conditions. With that increased use, annual per capita health care spending for those newly insured individuals (excluding out-of-pocket spending) is projected to grow from $2,677 to $6,370 in 2013 dollars, while their out-of-pocket spending would drop by $921. It is expected that these increases in spending would be offset at least in part by reductions in uncompensated care and charity care.

The Affordable Care Act's coverage expansions will reduce differences in uninsurance rates by race and ethnicity.

There are large differences in US health insurance coverage by racial and ethnic groups, yet there have been no estimates to date on how implementation of the Affordable Care Act will affect the distribution of coverage by race and ethnicity. We used a microsimulation model to show that racial and ethnic differentials in coverage could be greatly reduced, potentially cutting the eight-percentage-point black-white differential in uninsurance rates by more than half and the nineteen-percentage-point Hispanic-white differential by just under one-quarter. However, blacks and Hispanics are still projected to remain more likely to be uninsured than whites. Achieving low uninsurance under the Affordable Care Act will depend on effective state policies to attain high enrollment in Medicaid and the Children's Health Insurance Program and the new insurance exchanges. Coverage gains among Hispanics will probably depend on adoption of strategies that address language and related barriers to enrollment and retention in California and Texas, where almost half of Hispanics live. If uninsurance is reduced to the extent projected in this analysis, sizable reductions in long-standing racial and ethnic differentials in access to health care and health status are likely to follow.

Access to and use of paid sick leave among low-income families with children.

OBJECTIVE: The ability of employed parents to meet the health needs of their children may depend on their access to sick leave, especially for low-income workers, who may be afforded less flexibility in their work schedules to accommodate these needs yet also more likely to have children in poor health. Our goal was to provide rates of access to paid sick leave and paid vacation leave among low-income families with children and to assess whether access to these benefits is associated with parents' leave taking to care for themselves or others. METHODS: We used a sample of low-income families (<200% of the federal poverty level) with children aged 0 to 17 years in the 2003 and 2004 Medical Expenditure Panel Survey to examine bivariate relationships between access to and use of paid leave and characteristics of children, families, and parents' employer. RESULTS: Access to paid leave was lower among children in low-income families than among those in families with higher income. Within low-income families, children without >or=1 full-time worker in the household were especially likely to lack access to this benefit, as were children whose parents work for small employers. Among children whose parents had access to paid sick leave, parents were more likely to take time away from work to care for themselves or others. This relationship is even more pronounced among families with the highest need, such as children in fair or poor health and children with all parents in full-time employment. CONCLUSIONS: Legislation mandating paid sick leave could dramatically increase access to this benefit among low-income families. It would likely diminish gaps in parents' leave taking to care for others between families with and without the benefit. However, until the health-related consequences are better understood, the full impact of such legislation remains unknown.

Low income parents' reports of communication problems with health care providers: effects of language and insurance.

OBJECTIVES: This study examines how parental reports of communication problems with health providers vary over a wider range of characteristics of low income children than considered in previous studies. METHODS: Data were drawn from the 1999 and 2002 National Survey of America's Families. Communication problems, insurance type, socioeconomic characteristics, health factors, and provider type were examined. Data were analyzed using bivariate and multivariate techniques. RESULTS: Bivariate analysis identified that the parents of 24.4% of low income children and 36.4% of publicly covered low income children with a Spanish interview reported poor communication with health providers. Coefficients from regression analysis suggest that, controlling for covariates, foreign-born parents with a Spanish interview were 11.8 percentage points (p<0.01) more likely to report communication problems than U.S.-born parents with an English interview. Among low income publicly covered children with a Spanish interview, regression analysis suggests that parents of children who used clinics or hospital outpatient departments as their usual source of care were 9.5 percentage points (p<0.05) more likely to report communication problems compared with those whose usual source of care was a doctor's or HMO office. CONCLUSIONS: Implementing policies to improve communication barriers for low income children, particularly those with foreign-born parents whose native language is not English, may be necessary to reduce health disparities relative to higher income children across a variety of health domains including utilization, satisfaction, and outcomes. Focusing attention on the availability of professional translation services in clinics or hospital outpatient departments may be a cost-effective strategy for reducing communication problems for publicly insured children.

Toward universal coverage in Massachusetts.

This paper presents several options designed to help the Commonwealth of Massachusetts move to universal health insurance coverage. The alternatives all build upon a common base that includes an expansion of the Medicaid program, income-related tax credits, a purchasing pool, and government-sponsored reinsurance. These measures in themselves would not yield universal coverage, nor would an employer mandate by itself. We show that an individual mandate, and an employer mandate combined with an individual mandate, both would yield universal coverage with a relatively small increase in government costs relative to state gross domestic product and current health spending. The cost of an employer mandate--with a "pay or play" design--is sensitive to the payroll tax rate and base, the number and kind of exemptions, and whether workers whose employers "pay" receive discounts when they purchase health insurance. The development of these alternatives and their analyses contributed to the eventual health care compromise that emerged in Massachusetts in April 2006.