Medicaid Coverage and Access to Publicly Funded Opiate Treatment: Oregon

1
Medicaid Coverage and Access to Publicly Funded
Opiate TreatmentOregons ExperienceAHSRSanta
Monica, CA October, 2005

• Dennis Deck, Wyndy Wiitala, Kathy Laws
• RMC Research Corporation
• Portland, Oregon

2
Acknowledgements

• Funding sources
• NIDA R01 DA015060
• RWJ SAPRP 51530
• Collaborators
• Dennis McCarty, Bentson McFarland, OHSU
• Toni Krupski, Kevin Campbell, DASA
• John Mullooly, KCHR
• Roy Gabriel, RMC
• Data access
• Oregon DHS - OMAS and OMAP
• Presentation based on paper accepted for
  publication in JBHSR and updated trend data.

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Substance Abuse Treatment and Role of Medicaid

• Medicaid
• Primary payer of publicly funded outpatient
  treatment
• Especially true for opiate treatment, a chronic
  condition
• Important from both the client and providers
  perspective
• State context
• Some states (e.g. Oregon) have implemented
  various initiatives to expand eligibility or
  benefits
• Rising health care costs and recent budget
  deficits have put some of these initiatives at
  risk
• Legislatures pressured to make Medicaid budget
  neutral

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Oregon Health Plan

• OHP elements phased in
• Expanded eligibility to childless couples and
  single adults (Section 1115 waiver, 1994)
• Mandatory enrollment in managed care
• Prioritized list of covered services
• Integration of substance abuse treatment (1995)
• Prior studies
• Increase in number and rate entering outpatient
  treatment
• No evidence of decline in severity or outcomes
• Stability of eligibility important for access,
  retention, outcomes
• Increase in number but lower rate entering
  methadone
• Increase in methadone retention rates (1yr)

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Outpatient Access Rates (Percent of eligible
adults admitted during year)
Rate more than doubles despite shift to managed
care. Number served in substance abuse
treatment almost quadruples.
Deck et al (2000) JAMA
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Methadone Utilization Rates(MMT users per 1000
enrolled)
Increase driven by higher retention rates despite
managed care.
Capped system limits access and promotes
administrative discharges.
Deck Carlson (2003) JBHSR, Deck Carlson
(2004) JBHSR
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Oregon Health Plan 2

• New features (Section 1115 waiver renewed 2002)
• Split benefit
• OHP Plus (mandatory programs like TANF SSI
  full benefit)
• OHP Standard (expansion program reduced
  benefit)
• Increase cost sharing measures
• Greater enforcement of premium payment for OHPS
• Co-payments for some services
• Greater latitude to keep plan budget neutral
• Legislative emergency board action
• Eliminate SA/MH/dental services from OHPS benefit
  (including methadone)
• Announced Dec 02 but took effect Mar 03

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Hypothesis

• OHP Standard adults admitted for opiate
  addiction after cut (2003) will have reduced
  access to methadone relative to their
  counterparts before cut (2002) controlling for
• Selection bias due to Medicaid disenrollment
• Client characteristics that predispose or enable
  placement in methadone maintenance

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Methods

• Subjects
• 2,244 adults (ages 18-64) admitted to publicly
  funded treatment for opiate addiction
• 2002 and 2003 cohorts
• Quantitative Data
• State treatment database (Client Process
  Monitoring System CPMS)
• Linked records to Medicaid eligibility history
• Qualitative Data
• Interviews with providers and other key informants

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Analysis

• Access Rates
• Access Number placed in MMT / Number eligible
  1000
• Controls for enrollment decline but unadjusted
  for change in client mix
• Compare Cohorts using Propensity Score Analysis
• Find first opiate admission in 2002-03 and
  identify cohort
• Calculate Propensity Score (Rosenbaum and Rubin)
• Logistic Regression predicting 2003 cohort
• Enter admission characteristics as covariates
• Save predicted score for covariate in subsequent
  analysis
• Impute missing with second model dropping problem
  variables
• Test Hypothesis
• Logistic Regression predicting methadone
  placement
• Enter dummy variable for cohort (2003 vs 2002)
• Enter propensity score to control for client mix
• Enter additional covariates that are correlates
  of access

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Adult Enrollment in OHP
Monthly enrollment of adults (ages 18-64)
enrolled in the OHP. Historical (pre-2003)
eligibility codes were mapped to their OHP2
equivalents.
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Methadone Access RatesMedicaid eligible adults
admitted to MMT per thousand enrolled adults
From 2002 to 2003 (averaging Apr-Nov), we
observed a 58 decline for OHPS and 15 for OHP
R
A
E
Monthly adult methadone admissions divided by
number of adults enrolled in OHP times
1,000. ASA/MH benefit cut announced, Ecut takes
effect, Rbenefit restored but enrollment frozen
13
Shift in Client Mix Among OHPS Presenting for
Opiate Use
Comparison of cohorts on selected predictors with
significant differences.
14
Balancing Effect on Observed Covariates
MMT in past 2 yrs
Old (50-64)
Live in county w/o clinic
Not able to work
Groups defined by quintiles on propensity score.
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Model Predicting Access (Odds Ratios)

• 2003 Cohort (vs 2002) .40
• Predisposing
• Old (50 vs 25-49) 1.84
• Male (vs female) .61
• African Am (vs white) .41
• Need
• Meth/amph problem .54
• Alcohol problem .55
• Yrs opiate use (Ln) 2.47
• MMT in past 2 yrs 5.09

• Enabling
• Stable eligibility 1.60
• Self referral 3.68
• No clinic in cnty .25
• Not able to work .21
• Single .55
• Group home .23
• Homeless .36
• Propensity .00

All predictors significant at plt.01 or plt.001
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Qualitative Findings

• Client Perspective
• Medicaid disenrollment disproportionate among
  those with least ability to pay and least likely
  to have other source of coverage.
• Anecdotal reports of negative outcomes (e.g.
  suicide attempts, back on street, resumption of
  crime) as well as the pain of detoxification
• About half those in MMT when cut announced
  elected to pay out of pocket and thus forced to
  find ways to cover fees
• Though benefit was reinstated, only those still
  enrolled were eligible.
• Provider Perspective
• Anticipated huge loss of revenue and clients
• Clinic closures (2 of 12) and all reported staff
  layoffs
• Forced to titrate and prepare to discharge
  clients who could not pay
• Reduction in wraparound services
• State/Regional Perspective
• Isolated attempts to cover clients in treatment
• Eventual decision to reinstate benefit, some
  recognition that this was wrong place to cut

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Discussion

• Access
• Fewer OHPS clients presented for opiate
  treatment.
• Those that did were less than half as likely to
  be placed in methadone
• New admissions
• Proportionately fewer new opiate admissions
• Biggest cost offsets would be expected for this
  group
• System capacity
• Strong and immediate provider response
• OHP decline suggests possible spill over effect
  (even stronger with Outpatient SA and MH
  services)

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Limitations

• Oregons Medicaid expansion population may be
  somewhat unique (but no reason to expect
  different results with other poverty groups).
• Propensity score analysis only adjusts for
  observed covariates (but data set included rich
  source of covariates).
• Retrospective study using administrative
  databases (but covers the population rather than
  a small sample).

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Implications

• Benefit cut resulted in fewer seeking opiate
  treatment and less access to most appropriate
  source of care.
• Reasonable to assume that untreated opiate
  addiction may result in negative consequences in
  the form of arrests, ER use, mortality, etc.
• Thus, states would do well to consider the impact
  of cuts to leveraged services likely to have cost
  offsets.

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Preliminary HLM Results(36 months following
first opiate admission for cohorts presenting
1993-2000)
Outcome Time Varying Covariate OregonOR WashingtonOR
Enrolled in methadone during month Medicaid 9.7 3.9
Arrested during month Methadone .29 .30
Level 1 model month from admission, time
varying covariate, interactions Level 2 model
propensity for MMT and for Medicaid, prior
arrests, cohorts
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References

• Deck, D.D. , McFarland, B.H., Titus, J.M., Laws,
  K.E., Gabriel, R.M. (2000). Access to substance
  abuse treatment . Journal of American Medical
  Association. 284(16), 20932099
• Deck, D.D. Wiitala, W. Laws, K. (in press).
  Medicaid coverage and access to publicly funded
  opiate treatment. Journal of Behavioral Health
  Services and Research.
• Carlson, M.J., Gabriel, R.M., Deck, D.D., Laws,
  K.E., DAmbrosio, R. (2005). The impact of
  managed care on publicly funded outpatient
  adolescent substance abuse treatment Service use
  and 6-month outcomes in Oregon and Washington.
  Medical Care Research and Review, 62(3), 320-338.
• Deck, D.D. Carlson, M.J. (2005). Retention in
  methadone maintenance treatment in 2 western
  states. Journal of Behavioral Health Services
  Research, 32(1), 4360.
• Deck, D.D. Carlson, M.J. (2004). Access to
  publicly funded methadone maintenance treatment
  in two western states. Journal of Behavioral
  Health Services Research, 31(2), 164177.
• Deck, D.D. McFarland, B.H. (2002). Use of
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  after Medicaid managed care. Psychiatric
  Services, 53(7), 802.
• McFarland, B.H., Deck, D.D., McCamant, L.E.,
  Gabriel, R.M., Bigelow, D.A. (in press).
  Outcomes for Medicaid clients with substance
  abuse problems before and after managed care.
  Journal of Behavioral Health Services and
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• Rosenbaum P.R., Rubin D.B. (1984). Reducing bias
  in observational studies using subclassification
  on the propensity score. Journal of the American
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• Shadish, W.R., Clark, M.H. (2002). An
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