Because personal care and other home and community-based services (HCBS) are vulnerable to waste, fraud, and abuse, state Medicaid programs use prior authorization (PA) to improve program integrity [1]. However, little is known about Medicaid beneficiaries' experiences with PA for HCBS, even though physicians and consumers associate PA in general with delayed/denied care [2, 3]. We surveyed Virginia Medicaid beneficiaries to examine the timeliness of PA approval for in-home services. Administrative data suggest that only 3.9% of HCBS PAs in the state were denied since 2020; in the same period, 11.6% of authorizations took longer than 28 days [4]. We examined the association between PA approval delays and beneficiary characteristics, difficulty accessing HCBS, and health plan satisfaction. A novel feature of our survey is that all respondents were enrolled in the state's 1915(c) HCBS waiver and therefore had recent, documented functional and/or medical needs for HCBS, unlike representative surveys of consumers. The sampling frame consisted of community-dwelling Virginia Medicaid beneficiaries with at least 6 months of continuous coverage in their Medicaid health plan and the HCBS waiver, and the same Medicare coverage in the prior 6 months (Methods/Table S1). Details on the survey were published previously [5]. Outcomes included: (1) a binary measure of whether, in the past 6 months, the respondent reported delay "in getting approval for services from [their] Medicaid health plan for … care and other in-home services and conveniences that help with daily activities" (e.g., personal care, adult day care, and skilled nursing care); (2) a binary measure of whether, in the past 6 months, the respondent reported "difficulty accessing care and other in-home services and conveniences that help with daily activities"; and (3) Medicaid health plan satisfaction ranging from 0 ("worst plan possible") to 10 ("best plan possible"). Respondent demographic traits and eight measures capturing health, medical, and socioeconomic needs were defined from the survey (Methods S2). We conducted univariate analyses and chi-square tests of differences in delayed PA approval for HCBS by respondent trait. Using multivariate regression, we estimated adjusted differences in delayed PA approval (logit models) and examined the association of delayed PA approval with difficulty accessing in-home care (logit models) and plan rating (OLS) controlling for respondent characteristics. We assessed statistical significance using two-tailed tests and alpha of 0.05. A total of 2226 surveys of 6867 sent were returned, containing non-missing data on PA approvals for in-home services for 2136 respondents. One-third of respondents reported delayed PA approval for in-home services; delays did not differ by most demographic traits (Table S2). In univariate analysis, respondents with more health, medical, or socioeconomic needs were more likely to report delayed PA approval than those with less need (Table 1). For example, 40.8% of respondents with five or more chronic conditions reported delayed PA approval, compared to 31.0% of those with four or fewer conditions (p < 0.001); respondents who had problems getting enough food were more likely to report delayed PA approvals than those who did not (41.6% vs. 28.1%; [p < 0.001]). Adjusting for demographic traits, all need measures, and other types of delays, respondents with several measures of high need were significantly more likely to report delayed PA approval for HCBS (Table S3). Compared to respondents who did not report delayed PA approvals for in-home services, those who reported delays had higher odds of difficulty accessing in-home services (aOR = 6.74 [95% CI: 4.74–9.50], Table 2). Associations between difficulty accessing in-home services and delayed PA approval for medications or specialists were not statistically significant. Members reporting delayed PA approval for in-home services gave their health plans lower ratings (β = −0.21 [95% CI: −0.004 to −0.58], Table 2). Results were robust to sensitivity tests (Tables S4–S9). Our novel findings on Medicaid HCBS add to evidence from prior national studies that PA burden is generally greater for those with more health needs and that PA delays/denials are associated with reduced access and trust in the healthcare system [3, 6, 7]. While reports of delays may reflect respondents' unobserved traits (e.g., impatience), reporting other types of PA delays was not associated with difficulty accessing in-home services. Limitations include focusing on one state; like other surveys, delays were subjective and length was not defined [3], and persons experiencing delays may have been more likely to respond. We provide new cross-sectional evidence that delayed PA approval for Medicaid HCBS was associated with lower access and health plan ratings. Future work should explore whether access and satisfaction improve following regulations to lessen delays [8] and whether delays can be reduced by streamlining communication between providers, care coordinators, and plans, improving models of care, or using concurrent authorization [9, 10]. All authors meet the criteria for authorship stated in the Uniform Requirements for Manuscripts Submitted to Biomedical Journals. Jennifer M. Mellor designed the study and made substantial contributions to the acquisition of data, conducted the analysis and interpreted the data, drafted the article, and approved the final version to be published. Peter J. Cunningham and Erin Britton made substantial contributions to the acquisition of the data, revised the article critically for important intellectual content, and gave final approval of the version to be published. Andrew Mitchell and Sandra Dagenhart made substantial contributions to the analysis and interpretation of the data, revised the article critically for important intellectual content, and gave final approval of the version to be published. The authors have nothing to report. The authors declare no conflicts of interest. Data S1. Methods S1. Survey procedures. Table S1. Comparison of survey respondents and all surveyed members. Methods S2. Construction of variables measuring demographic traits, respondent needs, and other types of PA delays. Table S2. Differences in delays in PA approvals by demographic traits. Table S3. Adjusted odds ratio (aOR) from multivariate models of delays in PA approvals for in-home services for measures of interest. Table S4. Adjusted odds ratio (aOR) of delays in PA approvals for in-home services for measures of interest excluding respondents with missing data on demographic traits. Table S5. Adjusted odds ratio (aOR) of delays in PA approvals for in-home services for measures of interest controlling for type of Medicare coverage. Table S6. Adjusted odds ratio (aOR) of difficulty accessing in-home services for measures of interest excluding respondents with missing data on demographic traits. Table S7. Adjusted odds ratio (aOR) of difficulty accessing in-home services for measures of interest controlling for type of Medicare coverage. Table S8. Coefficient estimates for measures of interest from ordinary least squares (OLS) model of overall health plan rating excluding respondents with missing data on demographic traits. Table S9. Coefficient estimates for measures of interest from ordinary least squares (OLS) model of overall health plan rating controlling for type of Medicare coverage. Please note: The publisher is not responsible for the content or functionality of any supporting information supplied by the authors. Any queries (other than missing content) should be directed to the corresponding author for the article.

OBJECTIVE:We examined whether Medicaid expansion led to improvements in health, access, and preventive care for low-income adults with diabetes, varying by primary care provider (PCP) supply. RESEARCH DESIGN AND METHODS:Using 2011-2021 Behavioral Risk Factor Surveillance System data and a difference-in-differences approach, we compared outcomes before and after expansion in states classified by PCP supply. The sample included 85,375 adults aged 18-64 with incomes below 138% of the federal poverty level and a diabetes diagnosis. Outcomes were self-reported: health insurance coverage, personal doctor, cost-related delays in care, routine checkups, flu shots, and days with poor mental or physical health. RESULTS:Across all states, Medicaid expansion was associated with a 3.2 and 3.5 percentage-point (pp) increase in insurance coverage and checkup visits, respectively. High-PCP-supply states realized larger gains in coverage (6.4 pp) as well as improvements in routine checkups (3.3 pp) and flu vaccination (3.5 pp). They also showed a reduction of nearly one day of poor mental health per month. In contrast, low-PCP-supply states experienced a marginally significant increase in poor mental health days. CONCLUSIONS:Medicaid expansion improved coverage, preventive care, and mental health outcomes for low-income adults with diabetes, with more pronounced benefits in high-PCP-supply states. These findings underscore the importance of adequate PCP capacity to optimize the impact of coverage expansions in managing chronic conditions such as diabetes. Policymakers aiming to enhance care for vulnerable patients with diabetes should consider investing in primary care infrastructure alongside coverage expansions.

Objective:To understand relationships between healthcare use and food and housing insecurity in Medicaid expansion members, as well as whether these relationships differ by rurality or residential segregation. Data Sources and Study Setting:Database of Virginia Medicaid expansion members from the Department of Medical Assistance Services. Sample included individuals who enrolled January-June 2019, were aged 19-64 years, remained continuously enrolled for 12 months, and completed a Medicaid Member Health Screening (MMHS) conducted within the first 3 months of enrollment (n = 14,735). Study Design:Retrospective cohort study. Outcomes included any primary care visits (PC) and any emergency department (ED) visits in the first 12 months of enrollment. The MMHS sample was weighted to represent all Medicaid expansion members (n = 234,296). Separate multivariable linear probability models regressed having any PC or ED visits on food and housing insecurity controlling for individual and neighborhood characteristics. Models were then stratified by rurality and racial residential segregation. Data Collection: None. Principal Findings: Food insecurity was negatively associated with having any PC visit (-2.9 percentage points (PP); p-value <0.01) and positively associated with having any ED visit (7.0 PP; p-value <0.001). No significant relationships between PC or ED visits and housing insecurity were found. Suburban and urban individuals with food insecurity were significantly less likely to have any PC visit (p < 0.05 each). Medicaid expansion members living in disproportionately low-income or mixed-income neighborhoods experiencing food insecurity were also less likely to have any PC visits (p < 0.05), and the same was not true for those living in disproportionately high-income neighborhoods. Conclusions: Food insecurity among Medicaid expansion members is associated with less primary care and more emergency department use, but these relationships differ by the neighborhoods in which members live. Medicaid agency efforts that coordinate medical and social service benefits and also consider local context may further increase access to necessary and appropriate care.

Background: Payers are increasingly interested in quality improvement for opioid use disorder (OUD) treatment, including incorporating patient experiences. Medicaid is the largest payer for OUD treatment, yet we know little about the treatment benefits Medicaid members report, how these vary across members, or changed with the COVID-19 pandemic.Objective: To examine Medicaid members' report of outpatient treatment benefits, employment, and housing outcomes before and during the pandemic.Methods: A representative sample of 1,032 Virginia Medicaid members (52% women) receiving OUD treatment completed a survey of treatment benefits, health status and social needs. A reported treatment benefit index was created based on seven self-reported items. Multivariable linear regression models, pooled and stratified by time (pre-COVID-19/COVID-19), assessed member characteristics associated with reported treatment benefit, employment and housing outcomes.Results: Members reported strong treatment benefit (mean: 21.8 [SD: 5.9] out of 28 points) and improvements in employment (2.4 [1.3] out of 5) and housing (2.8 [1.2] out of 5). After adjustment, mental distress (regression coefficient: -3.00 [95% CI:-3.97;-2.03]), polysubstance use (-1.25 [-1.99;-0.51]), and food insecurity (-1.00 [-1.71;-0.29]), were associated with decreased benefits from treatment. During COVID-19, justice-involved individuals reported decreased benefits (-2.17 [-3.54; -0.80]) compared to before the pandemic (-0.09 [-1.4-;1.24] p < .05).Conclusions: Medicaid members receiving outpatient OUD treatment reported positive treatment benefits, and housing and employment outcomes. However, those with comorbid health and social conditions often benefited the least. As payers move toward quality improvement and value-based purchasing initiatives, collecting and integrating patient reported outcomes into quality metrics is critical.

Many state Medicaid programs contract with managed care organizations to deliver long-term services and supports (LTSS) to seniors and persons with disabilities. Managed LTSS (MLTSS) programs are often intended to increase access to and utilization of home- and community-based services (HCBS), yet there are few empirical studies of their effects. In this retrospective observational study, we used administrative data from Virginia Medicaid to compare HCBS waiver enrollment and service utilization pre- and post-implementation of MLTSS. Compared to the prior fee-for-service system, Medicaid beneficiaries with long-term care needs who were enrolled in Virginia's MLTSS program were more likely to be enrolled in Virginia's 1915(c) waivers for home and community-based services. Further, the likelihood of using personal care increased by nearly 5%, and the likelihood of using respite care increased by about 10%. These findings are pertinent to ongoing policy changes that use private managed care organizations to deliver long-term services and supports to seniors and persons with disabilities. Policymakers in states and the federal government should note these initial increases in service use under Medicaid MLTSS, while supporting evaluations of the long-term impacts of MLTSS on HCBS use and beneficiary health and satisfaction.

ImportanceDual Eligible Special Needs Plans (D-SNPs) are private managed care plans designed to promote Medicare and Medicaid integration for full-benefit, dually eligible beneficiaries. Currently, the highest level of D-SNP integration occurs in plans with exclusively aligned enrollment (EAE).ObjectiveTo compare patient experience of care, out-of-pocket spending, and satisfaction among dually enrolled Medicaid beneficiaries in D-SNPs with EAE, those in D-SNPs without EAE, and those with traditional Medicare.Design, Setting, and ParticipantsThis cross-sectional study included respondents to a mail survey fielded to a stratified random sample of full-benefit, community-dwelling, dual-eligible Medicaid beneficiaries who qualified for receipt of home and community-based services in the Virginia Medicaid Commonwealth Coordinated Care Plus program between March and October 2022.ExposureEnrollment in a D-SNP with EAE or a D-SNP without EAE vs traditional Medicare.Main Outcomes and MeasuresThe main outcomes were self-reported measures of access and delays in receiving plan approvals, out-of-pocket spending, and satisfaction with health plans’ customer service and choice of primary care and specialist physicians.ResultsOf 7200 surveys sent, 2226 were completed (response rate, 30.9%). The analytic sample consisted of 1913 Medicaid beneficiaries with nonmissing data on covariates (mean [SD] age, 70.8 [15.6] years; 1367 [71.5%] female). Of these, 583 (30.5%) were enrolled in D-SNPs with EAE, 757 (39.6%) in D-SNPs without EAE, and 573 (30.0%) in traditional Medicare. Compared with respondents enrolled in D-SNPs without EAE, those in D-SNPs with the highest level of integration (EAE) were 6.77 percentage points (95% CI, 8.81-12.66 percentage points) more likely to report being treated with courtesy and respect and 5.83 percentage points (95% CI, 0.21-11.46 percentage points) more likely to know who to call when they had a health problem. No statistically significant differences were found between members in either type of D-SNP and between those in D-SNPs and traditional Medicare in terms of their difficulty accessing care, delays in care, and satisfaction with care coordination and physician choice.Conclusions and RelevanceThis cross-sectional study found some benefits of integrating administrative processes under Medicare and Medicaid but suggests that care coordination and access improvements under full integration require additional time and/or efforts to achieve.

Background Shortages of providers authorized to prescribe buprenorphine may limit access to buprenorphine, which studies have shown to be effective in the treatment of opioid use disorder (OUD). Objective To examine whether two state Medicaid policies in Virginia—the Addiction and Recovery Treatment Services (ARTS) program in 2017, and Medicaid expansion in 2019—increased the number of buprenorphine waivered providers (BWP) in Virginia, compared to other southern states in the United States that did not expand Medicaid. Methods The study population includes providers authorized to prescribe buprenorphine. We compute the number of BWP per 100,000 people for the study states, overall and for different waiver limits (30, 100 or 275). Using difference-in-difference regression models, we examine changes in BWP rates for Virginia relative to nonexpansion states in the US South between 2015 and 2020. Results The rate of increase in BWP was higher in Virginia after implementation of ARTS and Medicaid expansion (148 %), compared to southern nonexpansion states over the same time period (115 %). Relative to nonexpansion states in the South, BWP with patient limits of 100 or 275 increased by 7 % in Virginia after ARTS implementation in 2017, and by an additional 22 % after Medicaid expansion in 2019 (p < 0.05 each). Conclusions The findings suggest that public policies that expand access to OUD treatment services—including buprenorphine treatment—may also increase the supply of providers authorized to prescribe buprenorphine, helping to alleviate shortages of BWP providers and further increasing access to care.

We evaluated the impact of Medicaid policies in Virginia (VA), namely the Addiction and Recovery Treatment Services (ARTS) program and Medicaid expansion, on the number of behavioral health acute inpatient admissions from 2016 to 2019. We used Poisson fixed-effect event study regression and compared average proportional differences in admissions over three time periods: (1) prior to ARTS; (2) following ARTS but before Medicaid expansion; (3) post-Medicaid expansion. The number of behavioral health acute inpatient admissions decreased by 2.6% (95% CI [−5.1, −0.2]) in the first quarter of 2018 and this decrease gradually intensified by 4.9% (95% CI [−7.5, −2.4]) in the fourth quarter of 2018 compared to the second quarter of 2017 (beginning of ARTS) in VA relative to North Carolina (NC). Following the first quarter of 2019 (beginning of Medicaid expansion), decreases in VA admissions became larger relative to NC. The average proportional difference in admissions estimated a decrease of 2.7% (95% CI, [−4.1, −0.8]) after ARTS but before Medicaid expansion and a decrease of 2.9% (95% CI, [−6.1, 0.4]) post-Medicaid expansion compared to pre-ARTS in VA compared to NC. Behavioral health acute inpatient admissions in VA decreased following ARTS implementation, and the decrease became larger after Medicaid expansion.

Background: Medicaid Long Term Services and Support (LTSS) programs serve individuals with complex medical and social needs. Increasingly, state Medicaid programs are contracting with managed care organizations to administer LTSS programs. Objectives: Understand the prevalence of and risk factors for unmet medical and social needs among a sample of patients within a Medicaid managed LTSS program. Methods: We surveyed a cross-sectional random sample of 798 community-residing individuals over 21 in Virginia who were served by the state Medicaid managed LTSS program. Outcomes of interest include 3 distinct medical needs: medical appointments, medical transportation, and prescriptions; 4 distinct social needs: housing security, food security, utility bills, and nonmedical transportation, and composite measures of unmet social and medical needs. Results: We found that 12.5% of our sample had any unmet medical need, while far more (62.2%) of our sample had any unmet social needs, with food insecurity being the most common. We found that members of color had almost 2 times the odds of having both unmet social and medical needs [social: adjusted odds ratio (aOR): 2.21; 95% confidence Interval (CI): (1.59, 3.09); medical aOR: 2.25 ; 95% CI: (1.34, 3.8)]. Conclusion: Medicaid members may not be fully realizing the potential of LTSS programs and would benefit from both Medicaid agency and managed care organizations' strategies aimed at addressing social drivers of health. To achieve health equity for LTSS members of color, Medicaid agencies may consider policies specifically targeting racial disparities.

Introduction: The overdose crisis is increasingly revealing disparities in opioid use disorder (OUD) outcomes by race and ethnicity. Virginia, like other states, has witnessed drastic increases in overdose deaths. However, research has not described how the overdose crisis has impacted pregnant and postpartum Virginians. We report the prevalence of OUD-related hospital use during the first year postpartum among Virginia Medicaid members in the years preceding the COVID-19 pandemic. We secondarily assess how prenatal OUD treatment is associated with postpartum OUD-related hospital use.Methods: This population-level retrospective cohort study used Virginia Medicaid claims data for live infant deliveries between July 2016 and June 2019. The primary outcome of OUD-related hospital use included overdose events, emergency department visits, and acute inpatient stays. Independent variables of interest were prenatal receipt of medication for OUD (MOUD) and receipt of non-MOUD treatment components in line with a comprehensive care approach (e.g., case management, behavioral health). Both descriptive and multivariate analyses were performed for all deliveries and stratified by White and Black non-Hispanic individuals to bring attention to the devastating impacts of the overdose crisis within communities of color.Results: The study sample included 96,649 deliveries. Over a third were by Black birthing individuals (n = 34,283). Prenatally, 2.5 % had evidence of OUD, which occurred more often among White (4 %) than Black (0.8 %) non-Hispanic birthing individuals. Postpartum OUD-related hospital use occurred in 10.7 % of deliveries with OUD, more commonly after deliveries by Black, non-Hispanic birthing individuals with OUD (16.5 %) than their White, non-Hispanic counterparts (9.7 %), and this disparity persisted in the multivariable analysis (Black AOR 1.64, 95 % CI 1.14-2.36). Postpartum OUD-related hospital events were less frequent for individuals receiving versus not receiving postpartum MOUD within 30 days prior to the event. Prenatal OUD treatment, including MOUD, was not associated with decreased odds of postpartum OUD-related hospital use in the race-stratified models.Conclusion: Postpartum individuals with OUD are at high risk for mortality and morbidity, especially Black individuals not receiving MOUD after delivery. An urgent need remains to effectively address the systemic and structural drivers of racial disparities in transitions of OUD care through the one-year postpartum period.

Introduction: Residential treatment is a key component of the opioid use disorder care continuum, but research has not measured well the differences in its use across states at the enrollee level. Methods: This cross-sectional observational study used Medicaid claims data from nine states to document the prevalence of residential treatment for opioid use disorder and to describe the characteristics of patients receiving care. For each patient characteristic, chi-square and t-tests tested for differences in the distribution between individuals who did and did not receive residential care.Results: Among 491,071 Medicaid enrollees with opioid use disorder, 7.5 % were treated in residential facilities in 2019, though this number ranged widely (0.3-14.6 %) across states. Residential patients were more likely to be younger, non-Hispanic White, male, and living in an urban area. Although residential patients were less likely than those without residential care to be eligible for Medicaid through disability, diagnoses for comorbid conditions were more frequently observed among residential patients.Conclusions: Results from this large, multi-state study add context to the ongoing national conversation around opioid use disorder treatment and policy, providing a baseline for future work.

BACKGROUND:Opioid use disorder is a leading cause of death through the year postpartum. OBJECTIVE:This study aimed to identify the association of neighborhood-level social determinants of health and prenatal opioid use disorder treatment receipt with the outcomes of medication treatment for opioid use disorder through the year postpartum among a cohort of birthing people. STUDY DESIGN:This was a population-based retrospective cohort study that used state Medicaid claims and enrollment data for the 1690 individuals who delivered a live infant between July 1, 2016 and December 31, 2020 and received medication for opioid use disorder at delivery. The primary exposure was the state Health Opportunity Index, a composite measure of social determinants of health linked at the census-tract level. Secondary exposures included comprehensiveness of opioid use disorder treatment and duration of medication treatment for opioid use disorder received prenatally. Outcomes included the duration and continuity of postpartum medication treatment for opioid use disorder, operationalized as the time from delivery to the discontinuation of medication treatment for opioid use disorder, and percentage of days covered by medication treatment for opioid use disorder within the 12 months after delivery, respectively. RESULTS:Within the study sample, 711 deliveries were to birthing people in the lowest state Health Opportunity Index tercile (indicating high burden of negative social determinants of health), 647 in the middle state Health Opportunity Index tercile, and 332 in the highest state Health Opportunity Index tercile. Using stepwise multivariable regression (Cox proportional hazards and negative binomial models) guided by a socioecological framework, prenatal receipt of more comprehensive opioid use disorder treatment and/or longer duration of prenatal medication treatment for opioid use disorder was associated with improved 1-year postpartum opioid use disorder treatment outcomes (duration and continuity of medication treatment for opioid use disorder). When the state Health Opportunity Index was added to the models, these significant associations remained stable, with the state Health Opportunity Index not demonstrating an association with the outcomes (duration hazard ratio, 1.39; 95% confidence interval, 0.551-3.512; continuity relative risk, 1.024; 95% confidence interval, 0.323-3.247). CONCLUSION:Targeted efforts at expanding access to and quality of evidence-based opioid use disorder treatments for reproductive-age people across the life course should be prioritized within the spectrum of work aimed at eradicating disparities in pregnancy-related mortality.

BACKGROUND:Many payers, including Medicaid, the largest payer of opioid use disorder (OUD) treatment, are pursuing treatment-related quality improvement initiatives. Yet, how patient-reported experiences with OUD treatment relate to patient-centered outcomes remains poorly understood. AIM:To examine associations between Medicaid members' OUD treatment experiences, outpatient treatment settings, demographic and social factors, and members' self-report of unmet needs during treatment and treatment discontinuation. METHODS:A sample of Virginia Medicaid members aged 21 years or older with OUD diagnoses who received outpatient OUD treatment completed a mail survey between January 2020 and August 2021 (n = 1042, weighted n = 9244). A treatment experience index was constructed from responses to four items from the Consumer Assessment of Healthcare Providers and Systems (CAHPS) relating to feelings of involvement, safety, and respect and having treatment explained in an understandable way; two additional CAHPS items: "given options for treatment" and "able to refuse treatment" were also assessed. Weighted imputed logistic regressions tested adjusted associations between members' treatment experiences, demographic and social factors, and two outcomes capturing unmet needs during treatment and treatment discontinuation. RESULTS:More positive scores on the treatment experiences index were associated with lower adjusted odds of reporting unmet needs during treatment (aOR: 0.52, 95% CI: 0.41-0.66) and discontinuation (aOR: 0.63, 95% CI: 0.47-0.79). Respondents with serious psychological distress had higher odds of reporting unmet needs during treatment (aOR: 1.69 95% CI: 1.14-2.51) and discontinuation (aOR: 1.84, 95% CI: 1.21-2.82), as did individuals with housing insecurity (unmet needs: (aOR: 1.65, 95% CI: 1.11-2.44); treatment discontinuation: (aOR: 1.56, 95% CI: 1.04-2.36)). CONCLUSION:Using a first-of-its-kind survey of Medicaid members with OUD, we found that members who had more positive treatment experiences were less likely to report unmet treatment needs and discontinue treatment. Care approaches focused on improving patient experience are critical to delivering effective, high-quality OUD treatment.

OBJECTIVES This paper examines (1) the rate of plan switching among beneficiaries enrolled in a Medicaid managed long-term services and supports (MLTSS) program in Virginia, (2) barriers that prevent beneficiaries from changing plans, and (3) the extent to which a change in plans is associated with greater satisfaction with the current health plan. STUDY DESIGN Survey data from a representative sample of 1048 members enrolled in Commonwealth Coordinated Care Plus, a Virginia Medicaid MLTSS program. METHODS The survey ascertained whether beneficiaries changed plans at the previous open enrollment period, whether they wanted to change plans but did not, and reasons for not following through with a plan change. Logistic regression analysis examined the association between the intention to change plans and satisfaction with the current health plan. RESULTS Seven percent of respondents changed plans during the previous open enrollment. However, twice as many respondents (15%) wanted to change plans but did not. The main reason for not changing plans was uncertainty about whether the new plan would meet their needs better than their current plan. Logistic regression analysis shows that an intention to change plans (realized or not) was associated with higher odds (3.5 times higher) of being dissatisfied with the current health plan compared with beneficiaries who had no intention to change plans. CONCLUSIONS Greater dissatisfaction after a recent plan change may indicate that these members have specific needs beyond the scope of services offered by managed care organizations.

Background: Follow-up after residential treatment is considered best practice in supporting patients with opioid use disorder (OUD) in their recovery. Yet, little is known about rates of follow-up after discharge. The objective of this analysis was to measure rates of follow-up and use of medications for OUD (MOUD) after residential treatment among Medicaid enrollees in 10 states, and to understand the enrollee and episode characteristics that are associated with both outcomes.Methods: Using a distributed research network to analyze Medicaid claims data, we estimated the likelihood of 4 outcomes occurring within 7 and 30 days post-discharge from residential treatment for OUD using multinomial logit regression: no follow-up or MOUD, follow-up visit only, MOUD only, or both follow-up and MOUD. We used meta-analysis techniques to pool state-specific estimates into global estimates.Results: We identified 90,639 episodes of residential treatment for OUD for 69,017 enrollees from 2018 to 2019. We found that 62.5% and 46.9% of episodes did not receive any follow-up or MOUD at 7 days and 30 days, respectively. In adjusted analyses, co-occurring mental health conditions, longer lengths of stay, prior receipt of MOUD or behavioral health counseling, and a recent ED visit for OUD were associated with a greater likelihood of receiving follow-up treatment including MOUD after discharge.Conclusions: Forty-seven percent of residential treatment episodes for Medicaid enrollees are not followed by an outpatient visit or MOUD, and thus are not following best practices.

BACKGROUND AND AIMS:Medication for opioid use disorder (MOUD) reduces harms associated with opioid use disorder (OUD), including risk of overdose. Understanding how variation in MOUD duration influences overdose risk is important as health-care payers increasingly remove barriers to treatment continuation (e.g. prior authorization). This study measured the association between MOUD continuation, relative to discontinuation, and opioid-related overdose among Medicaid beneficiaries.DESIGN:Retrospective cohort study using landmark survival analysis. We estimated the association between treatment continuation and overdose risk at 5 points after the index, or first, MOUD claim. Censoring events included death and disenrollment.SETTING AND PARTICIPANTS:Medicaid programs in 11 US states: Delaware, Kentucky, Maryland, Maine, Michigan, North Carolina, Ohio, Pennsylvania, Virginia, West Virginia and Wisconsin. A total of 293 180 Medicaid beneficiaries aged 18-64 years with a diagnosis of OUD and had a first MOUD claim between 2016 and 2017.MEASUREMENTS:MOUD formulations included methadone, buprenorphine and naltrexone. We measured medically treated opioid-related overdose within claims within 12 months of the index MOUD claim.FINDINGS:Results were consistent across states. In pooled results, 5.1% of beneficiaries had an overdose, and 67% discontinued MOUD before an overdose or censoring event within 12 months. Beneficiaries who continued MOUD beyond 60 days had a lower relative overdose hazard ratio (HR) compared with those who discontinued by day 60 [HR = 0.39; 95% confidence interval (CI) = 0.36-0.42; P < 0.0001]. MOUD continuation was associated with lower overdose risk at 120 days (HR = 0.34; 95% CI = 0.31-0.37; P < 0.0001), 180 days (HR = 0.31; 95% CI = 0.29-0.34; P < 0.0001), 240 days (HR = 0.29; 95% CI = 0.26-0.31; P < 0.0001) and 300 days (HR = 0.28; 95% CI = 0.24-0.32; P < 0.0001). The hazard of overdose was 10% lower with each additional 60 days of MOUD (95% CI = 0.88-0.92; P < 0.0001).CONCLUSIONS:Continuation of medication for opioid use disorder (MOUD) in US Medicaid beneficiaries was associated with a substantial reduction in overdose risk up to 12 months after the first claim for MOUD.

Introduction Follow-up visits within 7 days of an emergency department (ED) visit related to opioid use disorder (OUD) is a key measure of treatment quality, but we know little about its protective effect on future opioid-related overdoses. The objective this paper is to examine the rate of 7-day follow-up after an OUD-related ED visit and the association with future overdoses. Methods Retrospective analysis of Medicaid enrollees in 11 states that had an OUD-related ED visit from 2016 through 2018. Each state used Cox proportional hazard models to estimate the association between having a follow-up visit within 7 days of an OUD-related ED visit, and an overdose within 6 months of the ED visit. State analyses were pooled to generate global estimates using random effects meta-analysis. Results Among 114,945 Medicaid enrollees with an OUD-related ED visit, 15.7% had a follow-up visit within 7 days. State-specific rates varied from 7.2% to 22.4% across the 11 states. Compared to those with no follow-up visit, enrollees with a follow-up visit were more likely to be female, non-Hispanic White, less likely to have had an overdose or other substance use disorder at the time of the ED visit, and much more likely to have been receiving MOUD treatment prior to the ED visit. Global estimates based on multivariate analysis showed that having a 7-day follow-up visit was associated with a lower likelihood of overdose within 6 months of the index ED visit (HR = 0.91, CI = 0.84, 0.99). However, states had considerable heterogeneity in this association, with only two states having statistically significant results. Conclusions Among Medicaid enrollees with OUD, having a follow-up visit 7 days after an ED visit is protective against fatal or nonfatal overdose within 6 months, although the association varies considerably across states. Although the association with future overdoses was relatively modest, both practitioners and policymakers should seek to increase the number of Medicaid enrollees with OUD who receive follow-up care within 7 days after an ED visit.

Medicaid is a critical antipoverty program. Since the Affordable Care Act expanded Medicaid eligibility, millions of newly eligible people have enrolled, creating positive financial improvements for low-income families. We examined the association of Virginia's 2019 Medicaid expansion and changes in health care-related and non-health-care-related financial needs among newly eligible Medicaid enrollees. Our unique survey collected responses between December 2018 and April 2019 from newly enrolled members reporting on experiences in the year before enrollment and between July 2020 and May 2021 from members reporting on experiences one year after enrollment. The follow-up period coincided with the COVID-19 pandemic. Medicaid enrollment was associated with decreases in concern about all financial needs assessed: housing, food, monthly bills, credit card and loan payments, and health care costs. These reductions were broadly similar across demographic subgroups and across the months of the pandemic that overlapped with the follow-up period. We add to the evidence that Medicaid expansion is a social safety-net policy that could improve equity among low-income families, potentially encouraging states that have yet to expand to do so.

Importance There is limited information about trends in the treatment of opioid use disorder (OUD) among Medicaid enrollees. Objective To examine the use of medications for OUD and potential indicators of quality of care in multiple states. Design, Setting, and Participants Exploratory serial cross-sectional study of 1 024 301 Medicaid enrollees in 11 states aged 12 through 64 years (not eligible for Medicare) with International Classification of Diseases, Ninth Revision (ICD-9 or ICD-10) codes for OUD from 2014 through 2018. Each state used generalized estimating equations to estimate associations between enrollee characteristics and outcome measure prevalence, subsequently pooled to generate global estimates using random effects meta-analyses. Exposures Calendar year, demographic characteristics, eligibility groups, and comorbidities. Main Outcomes and Measures Use of medications for OUD (buprenorphine, methadone, or naltrexone); potential indicators of good quality (OUD medication continuity for 180 days, behavioral health counseling, urine drug tests); potential indicators of poor quality (prescribing of opioid analgesics and benzodiazepines). Results In 2018, 41.7% of Medicaid enrollees with OUD were aged 21 through 34 years, 51.2% were female, 76.1% were non-Hispanic White, 50.7% were eligible through Medicaid expansion, and 50.6% had other substance use disorders. Prevalence of OUD increased in these 11 states from 3.3% (290 628 of 8 737 082) in 2014 to 5.0% (527 983 of 10 585 790) in 2018. The pooled prevalence of enrollees with OUD receiving medication treatment increased from 47.8% in 2014 (range across states, 35.3% to 74.5%) to 57.1% in 2018 (range, 45.7% to 71.7%). The overall prevalence of enrollees receiving 180 days of continuous medications for OUD did not significantly change from the 2014-2015 to 2017-2018 periods (-0.01 prevalence difference, 95% CI, -0.03 to 0.02) with state variability in trend (90% prediction interval, -0.08 to 0.06). Non-Hispanic Black enrollees had lower OUD medication use than White enrollees (prevalence ratio [PR], 0.72; 95% CI, 0.64 to 0.81; P < .001; 90% prediction interval, 0.52 to 1.00). Pregnant women had higher use of OUD medications (PR, 1.18; 95% CI, 1.11-1.25; P < .001; 90% prediction interval, 1.01-1.38) and medication continuity (PR, 1.14; 95% CI, 1.10-1.17, P < .001; 90% prediction interval, 1.06-1.22) than did other eligibility groups. Conclusions and Relevance Among US Medicaid enrollees in 11 states, the prevalence of medication use for treatment of opioid use disorder increased from 2014 through 2018. The pattern in other states requires further research.

BACKGROUND:Primary care is crucial to the health of individuals and communities, but it faces numerous structural and systemic challenges. Our study assessed the state of primary care in Virginia to prepare for Medicaid expansion. It also provides insight into the frontline of health care prior to an unprecedented global COVID-19 pandemic.METHODS:We surveyed 1622 primary care practices to understand organizational characteristics, scope of care, capacity, and organizational stress.RESULTS:Practices (484) varied in type, ownership, location, and care for medically underserved and diverse patient populations. Most practices accepted uninsured and Medicaid patients. Practices reported a broad scope of care, including offering behavioral health and medication-assisted therapy for opioid addiction. Over half addressed social needs like transportation and unstable housing. One in three practices experienced a significant stress in 2019, prepandemic, and only 18.8% of practices anticipated a stress in 2020.CONCLUSIONS:Primary care serves as the foundation of our health care system and is an essential service, but it is severely stressed, under-resourced, and overburdened in the best of times. Primary care needs strategic workforce planning, adequate access to resources, and financial investment to sustain its value and innovation.