Improving racial equity in opioid use disorder treatment in Medicaid

摘要 获得阿片类药物使用障碍（MOUD）的药物是不公平的。黑人和西班牙裔人 接受MOUD和其他过量预防服务的可能性大大降低。吸毒过量死亡率 近年来，黑人的增长速度几乎是白色人的两倍，这种差距 在COVID-19大流行期间似乎有所扩大。收到MOUD时的种族/民族不平等是 植根于结构性种族主义，这种种族主义在医疗保健、住房、社会服务、刑事司法和其他方面的政策中根深蒂固， 司法和其他制度。作为MOUD最大的单一支付者和种族/民族保险的主要来源， 少数群体，医疗补助是很好的定位，以解决不平等的MOUD。虽然他们没有这样做， 医疗补助机构可以采取政策来改变（a）MOUD提供者的财务激励措施，以及（B） 与管理式护理计划签订合同，以提高MOUD的公平性。医疗补助计划可以建立 对提供者网络的要求;投资于为少数民族服务的医疗补助提供者的能力建设， 提供MOUD;在提供者绩效衡量中纳入公平措施;改变管理式医疗 合同，以激励计划，以解决MOUD中的不公平现象。然而，几乎没有证据表明， 这些杠杆最有可能是有效的。为了告知医疗补助政策的制定，我们利用医疗补助 结果分布式研究网络（MODRN），由大学与医疗补助计划合作组成 11个州的医疗机构代表了美国所有医疗补助注册者的22%。MODRN目前由NIDA资助， 研究医疗补助中阿片类药物使用障碍治疗的质量，并开发了分析基础设施， 对医疗补助中的MOUD治疗进行多状态分析。我们提出的分析研究的作用， 地方，供应商，计划和政策在MOUD中推动种族/民族不平等。首先，我们检查 医疗补助注册者中MOUD提供者的地理访问中的种族/民族不平等。二是 研究供应商和计划层面的因素对MOUD中种族/民族平等的贡献。第三，我们估计 旨在（a）改变提供系统改革和（B）管理式护理的国家政策之间的关联 合同和MOUD的股权。研究结果是MOUD的任何使用和MOUD的连续性，两者都是 与死亡率降低有关。我们将使用地理空间分析、多级建模和差分输入 差异分析，以实现我们的具体目标。与州医疗补助官员的长期关系 使我们能够直接与能够采取行动的决策者分享调查结果。MODRN有助于快速了解 从研究人员转移到政策制定者，允许州医疗补助机构对他们的表现进行基准测试， 种族/民族平等的MOUD对其他国家，并支持国家机构相互学习 关于提高MOUD公平性的最有效的政策杠杆。

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.