New research reveals significant gaps in substance use disorder (SUD) treatment coverage across state Medicaid managed care organizations (MCOs), potentially leaving many patients without access to crucial care.
MCOs cover the majority of Medicaid enrollees in the U.S., and SUD disproportionately impacts Medicaid populations. Over 20% of Medicaid enrollees have an SUD, compared with 16% among commercially insured populations.
However, at least half of states that contract with managed care plans do not require coverage for the full continuum of SUD services, according to a new study published in Health Affairs. This lack of coverage, coupled with MCOs’ discretion to utilize utilization management techniques, can limit patients’ access to timely care and saddle SUD providers with significant administrative burdens.
“We applaud that a high percentage of states are requiring coverages for a number of important substance use disorder treatment medications,” lead researcher Lauren Peterson, a doctoral candidate at the University of Chicago’s Crown Family School of social work, policy and practice, told Addiction Treatment Business. “But we want to note too that many states are not requiring all treatment services and medications across a continuum of care using recognized clinical guidelines.”
Researchers used data from 34 state programs, including Washington D.C., to analyze MCOs’ requirements for SUD treatment coverage.
Lack of coverage of the full continuum of care means patients may fall off the “step-down ladder” and not receive much-needed support, Colleen M. Grogan, professor of health policy in the Crown Family School of Social Work, Policy and Practice at the University of Chicago, told ATB in an email.
“An example of why it is important: when a person shows up at the ER in need of detoxification often times the next step in their care is intensive outpatient or residential treatment before they can step down to individual or group treatment,” Grogan said. “While the offering of MOUD is crucially important, these other services, like intensive outpatient [care], are needed to maintain MOUD and support the patient towards recovery.”
The study also collected data on which states employ common utilization management techniques. MCOs use these techniques, which include enrollee cost sharing, prior authorization and annual maximums, to ensure patients receive only appropriate care.
But these techniques can unnecessarily delay or deter patients from receiving necessary treatment, the study’s authors wrote.
Prior authorizations, for example, can delay the initiation of care at the “critical moment” when a person with an SUD needs treatment.
“Our study shows that most states allow their contracted MCOs to conduct utilization review with almost no state rules or oversight,” Grogan said. “The concern is, given the lack of data and oversight, we don’t know if unnecessary or necessary services are being denied. Especially for persons with OUD, when they are offered MOUD any delay in uptake can result in a lost opportunity for persons to engage in life-saving treatment.”
Prior authorizations and other utilization review techniques can negatively impact SUD providers and patients.
When faced with prior authorizations, SUD providers face significant administrative burdens and increased labor.
Some payer policies can prevent providers from providing optimal treatments. Fail-first requirements, for instance, mandate patients try and fail a payer’s preferred medication before granting coverage for an alternative treatment.
Need for increased transparency
Accessing data relating to managed care plans, even for researchers, is “really hard,” Peterson said. For patients, lack of access to information can make it exceedingly difficult to understand their benefits or to pick a plan.
Enhanced transparency and patient education regarding treatment access is crucial to empower patients to better understand their care options and enable researchers to formulate evidence-based recommendations for improving the current healthcare system, Peterson said.
However, researchers can make specific recommendations based on currently available data. While CMS requires that MCOs cover medications for opioid use disorder (MOUDs), it also needs to require the full continuum of care, Grogan said.
“CMS has done very little with regard to the numerous Medicaid MCO contracts across the states,” Grogan said. “When 75% of enrollees are in managed care, this means the vast majority of Medicaid enrollees are currently overlooked.”
