Improving racial equity in opioid use disorder treatment in Medicaid

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Abstract Access to medications for opioid use disorder (MOUD) is not equitable. Black and Hispanic individuals are substantially less likely to receive MOUD and other overdose prevention services. The overdose death rate has risen nearly twice as fast for Black individuals as for White individuals in recent years, a disparity that appears to have widened during the COVID-19 pandemic. Racial/ethnic inequities in receipt of MOUD are rooted in the structural racism ingrained in policies governing healthcare, housing, social services, criminal justice and other systems. As the largest single payer for MOUD and a key source of coverage for racial/ethnic minority groups, Medicaid is well-positioned to address inequities in MOUD. Although they have not done so to date, Medicaid agencies can adopt policies to alter (a) financial incentives for MOUD providers, and (b) contracts with managed care plans to improve equity in MOUD. Medicaid programs could institute requirements for provider networks; invest in building capacity for minority-serving Medicaid providers to deliver MOUD; include equity measures in provider performance measurement; and alter managed care contracts to incentivize plans to address inequities in MOUD. There is, however, little evidence on which of these levers is most likely to be effective. To inform Medicaid policy development, we harness the Medicaid Outcomes Distributed Research Network (MODRN), which is made up of university partnerships with Medicaid agencies in 11 states representing 22% of all US Medicaid enrollees. MODRN is currently funded by NIDA to study the quality of opioid use disorder treatment in Medicaid and has developed analytic infrastructure to conduct multi-state analyses of treatment with MOUD in Medicaid. We propose analyses that examine the role of place, providers, plans and policies in driving racial/ethnic inequities in MOUD. First, we examine racial/ethnic inequities in geographic access to MOUD providers among Medicaid enrollees. Second, we examine the contribution of provider- and plan-level factors to racial/ethnic equity in MOUD. Third, we estimate the association between state policies aimed at (a) changing delivery system reforms, and (b) managed care contracts, and equity in MOUD. Study outcomes are any use of MOUD and continuity of MOUD, both of which are associated with reduced mortality. We will use geospatial analyses, multi-level modeling, and difference-in difference analyses to accomplish our specific aims. Long-standing relationships with state Medicaid officials allow us to share findings directly with policymakers who can act on them. MODRN facilitates rapid knowledge transfer from researchers to policymakers, allows state Medicaid agencies to benchmark their performance on racial/ethnic equity in MOUD against other states, and supports state agencies learning from one another about the most effective policy levers for improving equity in MOUD.