Examining facilitative services for entry into substance use disorder treatment: A cluster analysis of treatment facilities.

OBJECTIVES: We examined services to facilitate access to entering substance use disorder (SUD) treatment among a national sample of SUD treatment facilities. METHODS: We analyzed data from the National Survey of Substance Abuse Treatment Services (N-SSATS) 2020. Facilities were included in the sample based on criteria such as SUD treatment provision and being in the U.S. Cluster analysis was conducted using variables including ownership, levels of care, and whether facilities provide services or accept payment options aimed at reducing treatment barriers. National and state-level data on the percentage of facilities in each cluster were presented. RESULTS: Among N = 15,788 SUD treatment facilities four distinct clusters were identified: Cluster 1 consisted of for-profit and government outpatient facilities with high proportions of services to reduce barriers (22.2%). Cluster 2, comprised of non-profit outpatient facilities, offered the most comprehensive array of services to minimize barriers to treatment among all four clusters (25.2%). Cluster 3 included facilities with diverse ownership and care levels and provided a moderate to high degree of services aimed at reducing entry barriers to treatment (26.0%). Cluster 4 was primarily for-profit outpatient facilities with a low proportion of these services (26.6%). CONCLUSIONS: This study revealed facility-level groupings with different services to reduce barriers to SUD treatment across various clusters of SUD treatment facilities. While some facilities offered extensive services, others provided fewer. Differences in cluster distributions point to possible facilitators to treatment access for some persons seeking admission to specific treatment facilities. Efforts should be made to ensure that individuals seeking SUD treatment can access these services, and facilities should be adequately equipped to meet their diverse needs.

Treatment setting and buprenorphine discontinuation: an analysis of multi-state insurance claims.

BACKGROUND: Potential differences in buprenorphine treatment outcomes across various treatment settings are poorly characterized in multi-state administrative data. We thus evaluated the association of opioid use disorder (OUD) treatment setting and insurance type with risk of buprenorphine discontinuation among commercial insurance and Medicaid enrollees initiated on buprenorphine. METHODS: In this observational, retrospective cohort study using the Merative MarketScan databases (2006-2016), we analyzed buprenorphine retention in 58,200 US adults with OUD. Predictor variables included insurance status (Medicaid vs commercial) and treatment setting, operationalized as substance use disorder (SUD) specialty treatment facility versus outpatient primary care physicians (PCPs) versus outpatient psychiatry, ascertained by linking physician visit codes to buprenorphine prescriptions. Treatment setting was inferred based on timing of prescriber visit claims preceding prescription fills. We estimated time to buprenorphine discontinuation using multivariable cox regression. RESULTS: Among enrollees with OUD receiving buprenorphine, 26,168 (45.0%) had prescriptions from SUD facilities without outpatient buprenorphine treatment, with the remaining treated by outpatient PCPs (n = 23,899, 41.1%) and psychiatrists (n = 8133, 13.9%). Overall, 50.6% and 73.3% discontinued treatment at 180 and 365 days respectively. Buprenorphine discontinuation was higher among enrollees receiving prescriptions from SUD facilities (aHR = 1.03[1.01-1.06]) and PCPs (aHR = 1.07[1.05-1.10]). Medicaid enrollees had lower buprenorphine retention than those with commercial insurance, particularly those receiving buprenorphine from SUD facilities and PCPs (aHR = 1.24[1.20-1.29] and aHR = 1.39[1.34-1.45] respectively, relative to comparator group of commercial insurance enrollees receiving buprenorphine from outpatient psychiatry). CONCLUSION: Buprenorphine discontinuation is high across outpatient PCP, psychiatry, and SUD treatment facility settings, with potentially lower treatment retention among Medicaid enrollees receiving care from SUD facilities and PCPs.

Enhanced Primary Care for People With Serious Mental Illness: A Propensity Weighted Cohort Study.

Objective: People with serious mental illness (SMI) have high rates of cardiometabolic illness, receive low quality care, and experience poor outcomes. Nevertheless, studies of existing integrated care models have not consistently shown improvements in cardiometabolic health for people with SMI. This study assessed the effect of a novel model of enhanced primary care for people with SMI on cardiometabolic outcomes. Enhanced primary care is a model of integrated care wherein comprehensive primary care delivery is adapted to the needs of people with SMI in coordination with behavioral care.Methods: We conducted a propensity-weighted cohort study comparing 234 patients with SMI receiving enhanced primary care to 4,934 patients with SMI receiving usual primary care using electronic health data from a large academic medical system covering the years 2014-2018. The propensity-weighted models controlled for baseline differences in outcome measures and patient characteristics between groups.Results: Compared to usual primary care, enhanced primary care increased hemoglobin A1c (HbA1c) screening by 18 percentage points (95% confidence interval [CI], 10 to 25), low-density lipoprotein (LDL) screening by 16 percentage points (CI, 8.8 to 24), and blood pressure screening by 7.8 percentage points (CI, 5.8 to 9.9). Enhanced primary care reduced HbA1c by 0.27 percentage points (CI, -0.47 to -0.060) and systolic blood pressure by 3.9 mm Hg (CI, -5.2 to -2.5) compared to usual primary care. We did not find evidence that enhanced primary care consistently affected glucose screening, LDL values, or diastolic blood pressure.Conclusions: Enhanced primary care can achieve clinically meaningful improvements in cardiometabolic health compared to usual primary care.

A mixed methods study of provider factors in buprenorphine treatment retention.

BACKGROUND: Low retention is a persistent challenge in the delivery of buprenorphine treatment for opioid use disorder (OUD). The goal of this study was to identify provider factors that could drive differences in treatment retention while accounting for the contribution of patient characteristics to retention. METHODS: We developed a novel a mixed-methods approach to explore provider factors that could drive retention while accounting for patient characteristics. We used Medicaid claims data from North Carolina in the United States to identify patient characteristics associated with higher retention. We then identified providers who achieved high and low retention rates. We matched high- and low-retention providers on their patients' characteristics. This matching created high- and low-retention provider groups whose patients had similar characteristics. We then interviewed providers while blinded to which belonged in the high- and low-retention groups on aspects of their practice that could affect retention rates, such as treatment criteria, treatment cost, and services offered. RESULTS: Less than half of patients achieved 180-day treatment retention with large differences by race and ethnicity. We did not find evidence that providers who achieved higher retention consistently did so by providing more comprehensive services or selecting for more stable patients. Rather, our findings suggest use of "high-threshold" clinical approaches, such as requiring participation in psychosocial services or strictly limiting dosages, explain differences in retention rates between providers whose patients have similar characteristics. All low-retention providers interviewed used a high-threshold practice compared to half of high-retention providers interviewed. Requiring patients to participate in psychosocial services, which were often paid out-of-pocket, appeared to be especially important in limiting retention. CONCLUSION: Providers who adopt low-threshold approaches to treatment may achiever higher retention rates than those who adopt high-threshold approaches. Addressing cost barriers and systemic racism are likely also necessary for improving buprenorphine treatment retention.

The Role of Primary Care in the Initiation of Opioid Use Disorder Treatment in Statewide Public and Private Insurance.

OBJECTIVE: To determine if individuals newly diagnosed with opioid use disorder (OUD) who saw a primary care provider (PCP) before or on the date of diagnosis had higher rates of medication treatment for OUD (MOUD). METHODS: Observational study using logistic regression with claims data from Medicaid and a large private insurer in North Carolina from January 2014 to July 2017. KEY RESULTS: Between 2014 and 2017, the prevalence of diagnosed OUD increased by 47% among Medicaid enrollees and by 76% among the privately insured. Over the same time period, the percent of people with an OUD who received MOUD fell among both groups, while PCP involvement in treatment increased. Of Medicaid enrollees receiving buprenorphine, the percent receiving buprenorphine from a PCP increased from 32% in 2014 to 39% in 2017. Approximately 82% of people newly diagnosed with OUD had a PCP visit in the 12 months before diagnosis in Medicaid and private insurance. Those with a prior PCP visit were not more likely to receive MOUD. Seeing a PCP at diagnosis was associated with a higher probability of receiving MOUD than seeing an emergency provider but a lower probability than seeing a behavioral health specialist or other provider type. CONCLUSIONS: People newly diagnosed with OUD had high rates of contact with PCPs before diagnosis, supporting the importance of PCPs in diagnosing OUD and connecting people to MOUD. Policies and programs to increase access to MOUD and improve PCPs' ability to connect people to evidence-based treatment are needed.

Universal screening for substance use by Peer Support Specialists in the Emergency Department is a pathway to buprenorphine treatment.

INTRODUCTION: Evidence suggests emergency department (ED)-initiated buprenorphine as efficacious in connecting ED patients to Medications for Opioid Use Disorder (MOUD) utilizing peer support specialists (PSS). However, there are no reports of implementation of ED-initiated buprenorphine in practice. Such information is crucial to support the adoption of ED-initiated buprenorphine. METHODS: In this quality improvement pilot study, a PSS screened ED patients over age 18 with the Tobacco, Alcohol, Prescription medication, and other Substance use - 1 (TAPS-1). The PSS considered the patient a positive screen if the patient met the following criteria: risky weekly alcohol use, illicit drugs, or prescription drugs. For patients who screened positive, the PSS delivered a brief intervention and assessed interest in treatment. An ED clinician assessed patients who screened positive for heroin/opioid use and were interested in treatment for buprenorphine induction. RESULTS: From January through June 2019, 1037 patients were screened for risky substance use, and, of these, 238 (23%) screened positive. The distribution of primary substance used was: 51% alcohol, 26% cannabis, 7.5% cocaine, 7.5% heroin, and 3.3% prescription opioids. Of the 23 patients who screened positive for heroin/opioid use and requested treatment, seven were admitted to the hospital. Of the remaining 16 patients, 14 patients wanted buprenorphine treatment, seven were provided buprenorphine in the ED, and four of these attended their intake appointments for community-based MOUD treatment. CONCLUSION: ED-initiated buprenorphine facilitated by a PSS is feasible and requires coordination and planning. Approaches to ED-initiated buprenorphine that screen only for opioid use will miss many patients interested in substance use treatment.

A scoping review of the use of ethnographic approaches in implementation research and recommendations for reporting.

BACKGROUND: Researchers have argued for the value of ethnographic approaches to implementation science (IS). The contested meanings of ethnography pose challenges and possibilities to its use in IS. The goal of this study was to identify sources of commonality and variation, and to distill a set of recommendations for reporting ethnographic approaches in IS. METHODS: We included in our scoping review English-language academic journal articles meeting two criteria: (1) IS articles in the healthcare field and (2) articles that described their approach as ethnographic. In March 2019, we implemented our search criteria in four academic databases and one academic journal. Abstracts were screened for inclusion by at least two authors. We iteratively develop a codebook for full-text analysis and double-coded included articles. We summarized the findings and developed reporting recommendations through discussion. RESULTS: Of the 210 articles whose abstracts were screened, 73 were included in full-text analysis. The number of articles increased in recent years. Ethnographic approaches were used within a wide variety of theoretical approaches and research designs. Articles primarily described using interviews and observational methods as part of their ethnographic approaches, though numerous other methods were also employed. The most cited rationales for using ethnographic approaches were to capture context-specific phenomena, understand insiders' perspective, and study complex interactions. In reporting on ethnographic approaches, we recommend that researchers provide information on researcher training and position, reflect on researchers' positionality, describe observational methods in detail, and report results from all the methods used. CONCLUSION: The number of IS studies using ethnography has increased in recent years. Ethnography holds great potential for contributing further to IS, particularly to studying implementation strategy mechanisms and understanding complex adaptive systems.

Effect of Enhanced Primary Care for People with Serious Mental Illness on Service Use and Screening.

BACKGROUND: Strategies are needed to better address the physical health needs of people with serious mental illness (SMI). Enhanced primary care for people with SMI has the potential to improve care of people with SMI, but evidence is lacking. OBJECTIVE: To examine the effect of a novel enhanced primary care model for people with SMI on service use and screening. DESIGN: Using North Carolina Medicaid claims data, we performed a retrospective cohort analysis comparing healthcare use and screening receipt of people with SMI newly receiving enhanced primary care to people with SMI newly receiving usual primary care. We used inverse probability of treatment weighting to estimate average differences in outcomes between the treatment and comparison groups adjusting for observed baseline characteristics. PARTICIPANTS: People with SMI newly receiving primary care in North Carolina. INTERVENTIONS: Enhanced primary care that includes features tailored for individuals with SMI. MAIN MEASURES: Outcome measures included outpatient visits, emergency department (ED) visits, inpatient stays and days, and recommended screenings 18 months after the initial primary care visit. KEY RESULTS: Compared to usual primary care, enhanced primary care was associated with an increase of 1.2 primary care visits (95% confidence interval [CI]: 0.31 to 2.1) in the 18 months after the initial visit and decreases of 0.33 non-psychiatric inpatient stays (CI: - 0.49 to - 0.16) and 3.0 non-psychiatric inpatient days (CI: - 5.3 to - 0.60). Enhanced primary care had no significant effect on psychiatric service and ED use. Enhanced primary care increased the probability of glucose and HIV screening, decreased the probability of lipid screening, and had no effect on hemoglobin A1c and colorectal cancer screening. CONCLUSIONS: Enhanced primary care for people with SMI can increase receipt of some preventive screening and decrease use of non-psychiatric inpatient care compared to usual primary care.

Barriers and perceived usefulness of an ECHO intervention for office-based buprenorphine treatment for opioid use disorder in North Carolina: A qualitative study.

BACKGROUND: Medication treatment for opioid use disorder (M-OUD) is underutilized, despite research demonstrating its effectiveness in treating opioid use disorder (OUD). The UNC Extension for Community Healthcare Outcomes for Rural Primary Care Medication Assisted Treatment (UNC ECHO for MAT) project was designed to evaluate interventions for reducing barriers to delivery of M-OUD by rural primary care providers in North Carolina. A key element was tele-conferenced sessions based on the University of New Mexico Project ECHO model, comprised of case discussions and didactic presentations using a "hub and spoke" model, with expert team members at the hub site and community-based providers participating from their offices (i.e., spoke sites). Although federal funders have promoted use of the model, barriers for providers to participate in ECHO sessions are not well documented. Methods: UNC ECHO for MAT included ECHO sessions, provider-to-provider consultations, and practice coaching. We conducted 20 semi-structured interviews to assess perceived usefulness of the UNC ECHO for MAT intervention, barriers to participation in the intervention, and persistent barriers to prescribing M-OUD. Results: Participants were generally satisfied with ECHO sessions and provider-to-provider consultations; however, perceived value of practice support was less clear. Primary barriers to participating in ECHO sessions were timing and length of sessions. Participants recommended recording ECHO sessions for viewing later, and some thought incentives for either the practice or provider could facilitate participation. Providers who had participated in ECHO sessions valued the expertise on the expert team; the team's ability to develop a supportive, collegial environment; and the value of a community of providers interested in learning from each other, particularly through case discussions. Conclusions: Despite the perceived value of ECHO, barriers may prevent consistent participation. Also, barriers to M-OUD delivery remain, including some that ECHO alone cannot address, such as Medicaid and private-insurer policies and availability of psychosocial resources.

Primary Care Providers And Specialists Deliver Comparable Buprenorphine Treatment Quality.

In response to rising numbers of opioid overdose deaths, primary care providers have been called on to play a greater role in delivering buprenorphine treatment for opioid use disorder. However, policy makers and providers have raised concerns that expanding treatment access may reduce treatment quality and that primary care providers are not well equipped to deliver buprenorphine treatment. We investigated two research questions in response to these concerns: How did buprenorphine treatment use and quality change in North Carolina Medicaid from 2014 to 2017, and how did buprenorphine treatment quality differ between primary care providers and specialists in North Carolina Medicaid during this period? We measured buprenorphine treatment quality as patients' retention in treatment and providers' adherence to treatment guidelines. We found that the number of enrollees receiving medication treatment for opioid use disorder increased substantially, but the percentage of enrollees with the disorder receiving treatment remained low. The quality of buprenorphine treatment increased during the study period, and primary care providers provided care of comparable or higher quality compared with that of other providers. Treatment quality for buprenorphine treatment is improving, but there remains room for improvement in both use and quality. Our results support the role of primary care providers in expanding treatment for opioid use disorder.

The effect of Medicaid expansion on use of opioid agonist treatment and the role of provider capacity constraints.

OBJECTIVE: To determine the effect of Medicaid expansion on the use of opioid agonist treatment for opioid use disorder (OUD) and to examine heterogeneous effects by provider supply and Medicaid acceptance rates. DATA SOURCES: Yearly state-level data on methadone dispensed from opioid treatment programs (OTPs), buprenorphine dispensed from OTPs and pharmacies, number of OTPs and buprenorphine-waivered providers, and percent of OTPs and physicians accepting Medicaid. STUDY DESIGN: This study used difference-in-differences models to examine the effect of Medicaid expansion on the amount of methadone and buprenorphine dispensed in states between 2006 and 2017. Interaction terms were used to estimate heterogeneous effects. Sensitivity analyses included testing the association of outcomes with Medicaid enrollment and state insurance rates. PRINCIPAL FINDINGS: The estimated effects of Medicaid expansion on buprenorphine and methadone dispensed were positive but imprecise, meaning we could not rule out negative or null effects of expansion. The estimated associations between state insurance rates and dispensed methadone and buprenorphine were centered near zero, suggesting that improvements in health coverage may not have increased OUD treatment use. The effect of Medicaid expansion was larger in the states with the most waivered providers compared to states with the fewest waivered providers. In the states with the most waivered providers, the average estimated effect of expansion on buprenorphine dispensed was 12 kg/y, enough to treat about 7500 individuals. We did not find evidence that the effect of expansion was consistently modified by OTP concentration, OTP Medicaid acceptance, or physician Medicaid acceptance. CONCLUSIONS: Gains in health coverage may not be sufficient to increase OUD treatment, even in the context of high treatment need. Provider capacity likely limited Medicaid expansion's effect on buprenorphine dispensed. Policies to increase buprenorphine providers, such as ending the waiver requirement, may be needed to ensure coverage gains translate to treatment access.

Opioid Prescribing Laws Are Not Associated with Short-term Declines in Prescription Opioid Distribution.

OBJECTIVE: To determine whether the adoption of laws that limit opioid prescribing or dispensing is associated with changes in the volume of opioids distributed in states. METHODS: State-level data on total prescription opioid distribution for 2015-2017 were obtained from the US Drug Enforcement Administration. We included in our analysis states that enacted an opioid prescribing law in either 2016 or 2017. We used as control states those that did not have an opioid prescribing law during the study period. To avoid confounding, we excluded from our analysis states that enacted or modified mandates to use prescription drug monitoring programs (PDMPs) during the study period. To estimate the effect of opioid prescription laws on opioid distribution, we ran ordinary least squares models with indicators for whether an opioid prescription law was in effect in a state-quarter. We included state and quarter fixed effects to control for time trends and time-invariant differences between states. RESULTS: With the exception of methadone and buprenorphine, the amount of opioids distributed in states fell during the study period. The adoption of opioid prescribing laws was not associated with additional decreases in opioids distributed. CONCLUSIONS: We did not detect an association between adoption of opioid prescribing laws and opioids distributed. States may instead wish to pursue evidence-based efforts to reduce opioid-related harm, with a particular focus on treatment access and harm reduction interventions.

Health Status and Access to Care for the North Carolina Medicaid Gap Population.

BACKGROUND North Carolina remains one of several states that has not expanded Medicaid eligibility criteria to cover all low-income adults, leading to the so-called Medicaid gap, a population ineligible for Medicaid and too poor for premium subsidies through the federal Health Insurance Marketplace. Our objective was to characterize the health care access and health status of the Medicaid gap population in North Carolina.METHODS We combined annual data from the Behavioral Risk Factor Surveillance Survey (2013-2016). Respondents who were uninsured and earning below 100% of the federal poverty guidelines (FPG) were classified as falling within the Medicaid gap and were compared to insured populations below FPG, representing the traditional Medicaid population, and to individuals above the FPG, regardless of insurance status. We reported health care access, receipt of preventive care, and current health status in unadjusted and demographically adjusted models.RESULTS Compared to either traditional Medicaid or above FPG groups, those in the Medicaid gap were 3 times as likely to have no regular source of care and twice as likely to report delaying needed care due to cost. Individuals in the Medicaid gap were more likely than individuals above FPG to report multiple chronic conditions (22% versus 16%) or a functional disability (35% versus 15%), but less likely than the traditional Medicaid population to do so.CONCLUSION While less likely than the traditional Medicaid population to have complex health needs, we found that individuals in the North Carolina Medicaid gap report numerous health care access barriers and lower use of preventive care.

Association Between State Minimum Wages and Suicide Rates in the U.S.

INTRODUCTION: The suicide rate in the U.S. has been increasing in recent years. Previous studies have consistently identified financial stress as a contributing factor in suicides. Nevertheless, there has been little research on the effect of economic policies that can alleviate financial stress on suicide rates. The purpose of this study is to determine whether increases in state minimum wages have been associated with changes in state suicide rates. METHODS: A retrospective panel data study was conducted. In 2018, linear regression models with state fixed effects were used to estimate the relationship between changes in state minimum wages and suicide rates for all 50U.S. states between 2006 and 2016. Models controlled for time-varying state characteristics that could be associated with changes in minimum wages and suicide rates. RESULTS: There were approximately 432,000 deaths by suicide in the study period. A one-dollar increase in the real minimum wage was associated on average with a 1.9% decrease in the annual state suicide rate in adjusted analyses. This negative association was most consistent in years since 2011. An annual decrease of 1.9% in the suicide rate during the study period would have resulted in roughly 8,000 fewer deaths by suicide. Analyses by race and sex did not reveal substantial variation in the association between minimum wages and suicides. CONCLUSIONS: Increases in real minimum wages have been associated with slower growth in state suicide rates in recent years. Increasing the minimum wage could represent a strategy for addressing increases in suicide rates.

The effect of referral to expedited Medicaid on substance use treatment utilization among people with serious mental illness released from prison.

Adults released from incarceration are at high risk of death from drug-related causes, pointing to the importance of connecting individuals to healthcare services after release from prison. Though Medicaid plays an important role in financing behavioral health treatments for vulnerable groups, many states terminate individuals' Medicaid coverage during incarceration. A significant risk factor for substance use disorders (SUD) among incarcerated individuals is serious mental illness (SMI). In January 2006, Washington State began a program of expedited Medicaid enrollment for individuals with mental illnesses being discharged from state prisons, jails, and psychiatric hospitals. Prior literature has shown this program to be effective in increasing Medicaid enrollment and use of mental health services for people with SMI. The current paper examined the effect of referral to expedited Medicaid on use of SUD treatment for people with SMI released from prison. Our sample consisted of 3086 individuals with a diagnosis of SMI who were released from prison from January 1, 2006 to December 31, 2007. Of the sample we identified, 871 individuals received referrals for expedited Medicaid and 2215 did not. To control for selection bias on observed characteristics for referral, we used inverse probability weights (IPW) to balance the referred and not-referred groups on more than 50 baseline covariates. We used doubly-robust IPW models to estimate the effect of referral to expedited Medicaid on use of SUD treatments following prison release. Approximately 12% of our sample used any SUD treatment by 3 months after release, with this percentage rising to 28% at 12 months. When controlling for baseline differences, referral to expedited Medicaid enrollment was associated on average with a 6.7 (SE 2.9, p < .05) percentage point increase in the predicted probability of using any SUD treatment in the 3 months following release as compared to those not referred to the program. This effect size represents a 61% increase in the probability of using any treatment by 3 months. The result was similar for the 6-month follow-up period and persisted at the 12-month follow-up though the magnitude of the effect decreased somewhat. Overall, our results suggest that expedited Medicaid enrollment for people with SMI released from prison can increase use of SUD services.

Effects of the Mental Health Parity and Addiction Equity Act on Specialty Outpatient Behavioral Health Spending and Utilization.

BACKGROUND: For decades, insurance plans in the United States have applied more restrictive treatment limits and higher cost-sharing burdens for mental health and substance use treatments compared to physical health treatments. The Mental Health Parity and Addiction Equity Act (MHPAEA) required health plans that offer mental health and substance use benefits to offer them at parity with physical health benefits starting in January 2010. AIMS OF THE STUDY: To determine the effect of MHPAEA on out-of-pocket spending and utilization of outpatient specialty behavioral health services. METHODS: The proportion of individuals with at least one outpatient specialty behavioral health visit, the average number of visits among those with any behavioral health visit, and the proportion of behavioral health spending paid out-of-pocket were obtained from the nationally-representative Medical Expenditure Panel Survey (MEPS) for the years 2006 to 2013. Difference-in-differences models were estimated comparing individuals with employer-sponsored insurance to those with Medicaid, Medicare, or who were uninsured. RESULTS: Out-of-pocket share of spending was lowest among Medicaid (2.0%) and highest among the uninsured (22%), followed by the employer group (13%). Individuals in Medicaid had the highest proportion of any behavioral health visit (11%) and the uninsured had the lowest (2.4%). Among those with any behavioral health visits, the average number of visits was similar across groups. Our primary and sensitivity analyses suggest MHPAEA did not lead to changes in utilization or spending on specialty outpatient behavioral visits for individuals with employer-sponsored insurance compared to other groups. DISCUSSION: Potential reasons for MHPAEA's apparent lack of effect are that health plans were already at parity before the law's passage, that many health plans continue to be out of compliance with the law, that concurrent changes in plans' cost-sharing blunted the law's effects, and that other barriers to behavioral health service use continue to limit utilization. While our study cannot provide direct evidence of these mechanisms, we review existing evidence in support of each of them. Our study had several limitations. We cannot test definitively whether the difference-in-differences assumption was violated or fully control for time-varying differences between groups. We attempt to address this by using multiple control groups and presenting evidence of parallel trends before MHPAEA implementation. Second, because our data do not have state identifiers, we cannot control for which states had existing mental health parity laws. Third, a nationally representative analysis may mask substantial heterogeneity for affected subgroups. IMPLICATIONS FOR HEALTH POLICIES: We find no evidence MHPAEA substantially affected behavioral health utilization or out-of-pocket spending. Federal parity legislation alone is likely insufficient to address barriers to behavioral health affordability and access.

Do naloxone access laws increase outpatient naloxone prescriptions? Evidence from Medicaid.

BACKGROUND: Naloxone is a prescription medication that can quickly and effectively reverse opioid overdose. Medicaid is a major payer of substance use disorder services, and Medicaid beneficiaries experience especially high rates of opioid overdose. As opioid overdose rates have risen sharply, every state has modified its laws to make naloxone easier to access. The aim of this paper is to determine whether implementation of different provisions of naloxone access laws led to increased naloxone dispensing financed by Medicaid. METHODS: We reviewed naloxone legislation passed by every state between 2007 and 2016. We used the Medicaid State Drug Utilization dataset to examine the effect of different types of state naloxone access law provisions, separately and as a whole, on the number of outpatient naloxone prescriptions reimbursed by Medicaid from 2007 to 2016. We included state-level covariates in our models that may be correlated with naloxone utilization in Medicaid and passage of naloxone access laws. RESULTS: We found that the presence of any naloxone law was significantly associated with increases in outpatient naloxone reimbursed through Medicaid. Laws containing standing order provisions were most consistently associated with increases in naloxone dispensing across models. Standing order provisions led on average to an increase of approximately 33 naloxone prescriptions per state-quarter, which is equivalent to 74% of the average number of naloxone prescriptions per state-quarter. CONCLUSIONS: Naloxone access laws, particularly those with standing order provisions, appear to be an effective policy approach to increasing naloxone access among Medicaid beneficiaries.

Expedited Medicaid Enrollment, Service Use, and Recidivism at 36 Months Among Released Prisoners With Severe Mental Illness.

OBJECTIVE: This study examined long-term outcomes (at 36 months) from Washington State's policy of expediting Medicaid enrollment for prison releasees with severe mental illness and compares them with previously reported short-term outcomes (at 12 months). METHODS: Linked administrative data on prison releasees (2006-2007) were analyzed by using a quasi-experimental design comparing those referred to expedited Medicaid (N=895) with a control group of those not referred (N=2,189). Aggregate outcomes were analyzed with inverse probability of treatment-weighted logit models. RESULTS: Expedited Medicaid had a sustained effect on both increased months of enrollment (p<.01) and increased use of community mental health and general medical services (p<.01) 36 months after prison release. However, expedited Medicaid did not reduce criminal recidivism, consistent with 12-month findings, Conclusions: Outcome results at 12 months were sustained at 36 months-namely, expedited Medicaid for released prisoners with severe mental illness improved enrollment and service use with no effects on criminal recidivism.