State Medicaid Agencies’ Multifaceted Response to the Opioid Epidemic

Medicaid is the single largest payer for opioid use disorder (OUD) treatment. State Medicaid programs covered an estimated 38% of nonelderly adults with opioid use disorder (OUD) in 2017, and 54% of those who received treatment for OUD. To advance knowledge about the multiple facets of state Medicaid policy adoption and implementation, we conducted in-depth interviews in 2019 with policy officials from nine states — Kentucky, Maryland, Michigan, North Carolina, Ohio, Pennsylvania, Virginia, West Virginia, and Wisconsin — that participate in a multistate Medicaid collaborative project: the Medicaid Outcome Distributed Research Network (MODRN). Many of these states have been hard hit by the opioid crisis.

Although our interviews were conducted prior to the COVID-19 pandemic, states will need to continue to test and modify their substance use disorder (SUD) policies given the negative economic and health effects of the pandemic. In addition, during the pandemic, federal regulations have been relaxed to facilitate OUD treatment while limiting face-to-face contact, including increased allowed amounts of take-home methadone, waiving the need for in-person consultations to start buprenorphine and routine urine drug tests. Our findings from these nine states may help other states as they reconsider their SUD policies at this critical moment.

As detailed in our recent AcademyHealth report, State Medicaid Agencies’ Multi-Faceted Response to the Opioid Epidemic, we found a high degree of convergence in the pre-COVID approaches to implement OUD treatment policies taken by these nine states. Given the latitude that state policymakers have to shape their Medicaid programs, the trends outlined below were noteworthy.

Relaxed utilization management policies for medications for opioid use disorder (MOUD), such as prior authorization. All nine states relaxed their utilization management policies between 2014 and 2019. State Medicaid officials explained that any potential quality gains achieved through utilization management policies were not worth any potential restriction on access. One state shifted from allowing Medicaid managed care organizations (MCOs) to set their own prior authorization criteria to a single program-wide set of prior authorization criteria to reduce the administrative burden on providers and encourage more of them to offer MOUD. The majority of states did not have monitoring requirements for continuation of MOUD, such as frequency of urine drug tests or behavioral health counseling, citing other utilization management policies like dosage limits and relying on the provider to adhere to what is medically appropriate as sufficient controls for MOUD prescribing.

Expansion of the continuum of services covered for SUD treatment. Facilitated by the adoption of new American Society of Addiction Medicine (ASAM) criteria defining the SUD continuum of care, between 2014 and 2019, six of the nine states expanded Medicaid coverage of residential SUD care, three began covering inpatient SUD services, three began reimbursing for peer support, and three added or expanded coverage for partial hospitalization services. Seven of the states reported using ASAM criteria to guide coverage decisions. Among the two states that did not use ASAM criteria, one allowed Medicaid managed care organizations (MCOs) to use alternative criteria that could not be more restrictive than ASAM, and the other allowed providers to choose either ASAM or the Clinical Opiate Withdrawal Scale.

Extensive multi-agency collaboration to address the opioid epidemic. All nine states established interagency task forces or command centers, which were typically overseen by the state’s governor and brought together leaders from multiple state agencies on a regular basis to identify problems, share information, and advance programs. Medicaid agencies frequently collaborated with state departments of corrections to expand access to MOUD for individuals with OUD in jails and prisons.

Interest in value-based purchasing for SUD treatment. The states have primarily focused on increasing access to OUD treatment (and rightfully so), but attention appears to be shifting toward improving the quality of OUD care. One strategy to improve OUD care is value-based purchasing for SUD treatment. We found that states are interested, but the lack of standardized quality metrics on SUD treatment may be hindering the pursuit of value-based purchasing that would tie payment to quality and outcome measures. Some states reported that they monitor levels of prescribed opioids, inpatient and ED use for OUD, duration of MOUD pharmacotherapy, retention in treatment, and counseling rates, while others reported that they were still identifying measures to target. Researchers and national health care quality measurement organizations, such as the National Quality Foundation, the National Committee for Quality Assurance, should partner with state policymakers to fill this void.

Given the expansion of SUD treatment services available to many Medicaid enrollees in these states and others, more research is needed on what treatment yields the best outcomes and for whom. The pandemic only intensified this need; recent data have shown that drug overdose deaths increased by approximately 30% during the first 12 months of the pandemic.

As the pandemic eases, state and federal policymakers should carefully consider whether all regulations need to be restored. Studies on the impact of relaxed utilization management policies, for example, would inform policies by quantifying the gains in access and any potential tradeoffs in quality. We believe partnerships between researchers and state policymakers, such as MODRN, are vital to providing evidence that will help policymakers improve care for Medicaid enrollees.