A conversation with Lauren Peterson

by Jon Scaccia August 12, 2024

Lauren A. Peterson, a doctoral student at the Crown School of Social Work, Policy, and Practice, is at the forefront of research into the variability and impact of Medicaid policies on Substance Use Disorder (SUD) treatment. Her recent study sheds light on the discretionary powers held by Medicaid-managed care plans, which can significantly influence access to lifesaving treatments. In an era where the United States grapples with a severe drug epidemic, Peterson’s work underscores the need for consistent and equitable healthcare policies.

We were able to ask some questions about the implications of her research.

Can you tell us the main findings of your study and how different states’ Medicaid plans treat substance use disorder differently?

We found that the state Medicaid programs that contracted with managed care plans to cover substance use disorder (SUD) benefits required coverage for at least some critical SUD treatments, particularly medications for opioid use disorder and related services, which the SUPPORT Act currently mandates. However, only half of the state Medicaid programs that contracted with managed care plans required them to cover SUD treatment services across the continuum of care, as broadly defined by the American Society of Addiction Medicine. Approximately three-quarters of the state Medicaid programs mandated coverage of all nine medications approved by the Food and Drug Administration (FDA) for the treatment of SUD that we included in this study. While we applaud state Medicaid programs’ commitment to mandating coverage for at least some SUD treatments in managed care, we are concerned that many state Medicaid programs do not require managed care plans to cover the full continuum of SUD care.

We also found that state Medicaid programs gave managed care plans a high degree of discretion in implementing utilization management strategies for SUD treatments. In particular, few state Medicaid programs prohibit managed care plans from imposing prior authorizations for each SUD treatment service or medication that we examined in our study. Notable numbers of state Medicaid programs also afforded managed care plans deference regarding utilization management strategies that are more specific to SUD treatment, including drug testing, fail-first or step-down policies, and psychosocial therapy requirements. While most state Medicaid programs do prohibit enrollee cost-sharing (co-payments/deductibles) and annual maximums, some states continue to give managed care plans discretion in these areas. Given the limited state Medicaid program oversight and available data on Medicaid managed care plans, we do not know if these utilization management strategies limit unnecessary care or if they may restrict access to lifesaving SUD treatments and continuity of care.

What do these differences mean for public health workers in states with fewer rules about substance use treatment?

Managed care plans play an increasingly prominent role in the U.S. healthcare system. Approximately 75% of all Medicaid enrollees are covered by managed care plans. In some states, all Medicaid enrollees are covered by managed care plans. As a result, benefit coverage and utilization management policies can vary not only by state but also by Medicaid managed care plan, particularly in states with less oversight and regulation around substance use treatment benefits.

Individuals enrolled in Medicaid managed care plans in states with fewer coverage requirements – including the 50% of states that contract with these plans to cover substance use disorder treatment services that do not mandate coverage of the full continuum of care. While providing medications for opioid use disorder (MOUD) is critically important, these other SUD treatment services are needed to maintain MOUD and support the patient toward recovery. For example, when someone shows up in the emergency department in need of detoxification, oftentimes, the next step in their care is intensive outpatient or residential treatment before they can step down to individual or group treatment.  When the full continuum of care is not required, Medicaid managed care enrollees in these states fall off the SUD treatment stepdown ladder and do not receive the support they need. 

Overall, for public health workers, the primary concern is that without state oversight and regulation, utilization management strategies may be applied in ways that are inconsistent with clinical recommendations and may limit timely access to effective SUD treatments. From the provider’s perspective, prior authorizations and other utilization management strategies create high levels of administrative burden and make it more difficult for them to practice sound patient care.

How do rules like needing approval first or drug testing affect how quickly people can get treatment, and what can health workers do to help patients get around these issues?

Utilization management strategies can introduce additional barriers to care. Prior authorization can increase wait times for lifesaving SUD treatment, potentially missing a critical window in which an individual is willing to seek care or disrupting the continuity of care. “Fail first” or step-down policies can delay access to the optimal SUD treatment for an individual when providers must demonstrate that lower-cost options are not effective. Drug testing and psychosocial therapy requirements may also delay or deter individuals from seeking SUD treatment, particularly given the shortage of mental health service providers.

Health workers need more support from policymakers to address these issues. Our study shows that most states allow their contracted MCOs to impose utilization management strategies with almost no state rules or oversight. Further, Centers for Medicare and Medicaid Services provides very little guidance or regulation regarding Medicaid managed care contracts with states. An additional concern is the lack of data and oversight of Medicaid managed care plans, which is liming our understanding of the extent to which necessary SUD treatment services and medications are being delayed or denied.

With the opioid crisis and more people needing help for substance use, what changes do you think should be made to make sure everyone gets the treatment they need?

While the Substance Use Disorder Prevention that Promotes Opioid Recovery and Treatment for Patients and Communities (SUPPORT) Act of 2018 requires all state Medicaid programs and contracted managed care plans to cover three critical forms of MOUD until 2025, few other regulations are in place to ensure adequate coverage for SUD treatment, as defined by the clinical guidelines for management of SUD established by the American Society of Addiction Medicine (ASAM). Centers for Medicare and Medicaid Services should require coverage of the full continuum of SUD care in alignment with these clinical guidelines.

How can public health workers help push for better treatment options and fairer rules in Medicaid plans for substance use disorder?

Data and oversight are crucially important. We also believe there is a need for greater transparency regarding Medicaid managed care plan benefits and policies. Right now, it is incredibly difficult for researchers to obtain this information to provide an evidence base on the effects of utilization management strategies on access to SUD treatment and continuity of care. Greater transparency is also critical for Medicaid managed care enrollees to select the best available plan for their needs.

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