The Effects of States' Substance Use Waivers on Healthcare Utilization and Opioid-related Overdoses Among Medicaid Enrollees with Opioid Use Disorder

项目摘要 阿片类药物滥用是一场公共卫生危机：2016年，210万人患有阿片类药物使用障碍（OUD）， 超过4万人死于阿片类药物过量。有明确的证据表明，OUD患者可以 使用药物和行为干预（如咨询）进行有效治疗。取决于 成瘾的严重程度，治疗可以在门诊环境中进行（例如，个体治疗的门诊访视）或 可能需要在住院机构（如住宅设施或医院）进行更深入的护理。但 大部分OUD患者仍然没有得到最佳治疗。 医疗补助在解决阿片类药物危机方面发挥着关键作用。它涵盖了近40%的医疗保健， OUD患者和州医疗补助计划提供各种影响健康的OUD治疗服务 对患有OUD的人来说，其中一些福利是联邦政府规定的（例如，住院或艾德服务 在综合医院中），而其它是可选的（例如，药物，病例管理），并由公众 国家一级的决策。然而，目前尚不清楚什么样的政策最能成功地减少 医疗补助受益人中阿片类药物过量的数量。 2015年，医疗保险和医疗补助服务中心（CMS）发布了指导意见，允许各州接受 联邦资金通过第1115条医疗补助豁免支持物质使用治疗“机构 精神疾病”（IMDs），定义为拥有超过16张床位的专门从事精神健康或 物质使用治疗。在没有这些豁免的情况下，联邦法律禁止各州使用联邦 匹配资金以支付IMD提供的医疗补助服务。豁免放松了这一禁令，而 同时要求各国实施各种其他变革，包括，例如， OUD覆盖率，阿片类药物治疗指南和提供者之间的护理协调。目前，已有27个国家 获得了SUD豁免。 本申请提出了一个综合的混合方法评估医疗补助SUD的影响 豁免实施。我们的建议有三个目的。首先，我们使用医疗补助索赔数据来检查效果 医疗保健利用豁免，包括随着时间的推移（2014-2021年）和各州的药物使用。 其次，我们评估豁免对阿片类药物相关过量的影响。第三，我们将联合收割机的定量结果 定性数据收集，以确定与 成功减少阿片类药物过量。拟议的研究将提供关键信息， 州医疗补助计划关于最成功地解决阿片类药物危机的公共政策。

Project summary Abuse of opioids is a public health crisis: in 2016, 2.1 million people had an opioid use disorder (OUD) and more than 40,000 people died from an opioid overdose. There is clear evidence that people with OUD can be effectively treated using medication and behavioral interventions such as counseling. Depending on the severity of the addiction, treatment can occur in outpatient settings (e.g., office visits for individual therapy) or might require more intensive care in inpatient settings such as residential facilities or hospitals. However, a large share of people with OUD still do not receive optimal treatment. Medicaid plays a crucial role in addressing the opioid crisis. It covers health care for almost 40 percent of people with OUD, and state Medicaid programs provide a variety of OUD treatment services affecting health outcomes for people with OUD. Some of these benefits are federally mandated (e.g., inpatient or ED services in general hospitals), while others are optional (e.g., medications, case management) and determined by public policy decisions at the state level. However, it is not clear what kind of policies are most successful in reducing the number of opioid overdoses among Medicaid beneficiaries. In 2015, the Centers for Medicare & Medicaid Services (CMS) issued guidance allowing states to receive federal funding to support substance use treatment through Section 1115 Medicaid waivers for “Institutions for Mental Diseases” (IMDs), defined as facilities with more than 16 beds that specialize in mental health or substance use treatment. In the absence of these waivers, federal law prohibits states from using federal matching funds to pay for Medicaid services provided in IMDs. The waivers relax this prohibition, while simultaneously requiring states implement a variety of other changes, including, for example, comprehensive OUD coverage, opioid treatment guidelines and care coordination among providers. Currently, 27 states have received an SUD waiver. This application proposes a comprehensive mixed-methods assessment of the effects of the Medicaid SUD waiver implementation. Our proposal has three aims. First, we use Medicaid claims data to examine the effect of the waiver on health care utilization, including medication use over time (2014-2021) and across states. Second, we assess the effect of the waiver on opioid-related overdoses. Third, we combine quantitative results with qualitative data collection to identify waiver elements and contextual factors that were associated with a successful reduction in opioid-related overdoses. The proposed research will provide critical information to state Medicaid programs about public policies that are most successfully addressing the opioid crisis.