U.S. Department of Health and Human Services

Assistant Secretary for Planning and Evaluation

Office of Disability, Aging and Long-Term Care Policy

BEST PRACTICES AND 

BARRIERS TO ENGAGING 

PEOPLE WITH

SUBSTANCE USE DISORDERS

IN TREATMENT

March 2019
Office of the Assistant Secretary for Planning and Evaluation

The Office of the Assistant Secretary for Planning and Evaluation (ASPE) is the 

principal advisor to the Secretary of the Department of Health and Human Services 

(HHS) on policy development issues, and is responsible for major activities in the areas 

of legislative and budget development, strategic planning, policy research and 

evaluation, and economic analysis.

ASPE develops or reviews issues from the viewpoint of the Secretary, providing a 

perspective that is broader in scope than the specific focus of the various operating 

agencies. ASPE also works closely with the HHS operating agencies. It assists these 

agencies in developing policies, and planning policy research, evaluation and data 

collection within broad HHS and administration initiatives. ASPE often serves a 

coordinating role for crosscutting policy and administrative activities.

ASPE plans and conducts evaluations and research--both in-house and through support 

of projects by external researchers--of current and proposed programs and topics of 

particular interest to the Secretary, the Administration and the Congress.

Office of Disability, Aging and Long-Term Care Policy

The Office of Disability, Aging and Long-Term Care Policy (DALTCP), within ASPE, is 

responsible for the development, coordination, analysis, research and evaluation of HHS 

policies and programs which support the independence, health and long-term care of persons 

with disabilities--children, working aging adults, and older persons. DALTCP is also responsible 

for policy coordination and research to promote the economic and social well-being of the 

elderly.

In particular, DALTCP addresses policies concerning: nursing home and community-based 

services, informal caregiving, the integration of acute and long-term care, Medicare post-acute 

services and home care, managed care for people with disabilities, long-term rehabilitation 

services, children’s disability, and linkages between employment and health policies. These 

activities are carried out through policy planning, policy and program analysis, regulatory 

reviews, formulation of legislative proposals, policy research, evaluation and data planning.

This report was prepared under contract #HHSP23320100022WI between HHS’s 

ASPE/DALTCP and Truven Health Analytics. For additional information about this subject, you 

can visit the DALTCP home page at https://aspe.hhs.gov/office-disability-aging-and-long-termcare-policy-daltcp or contact the ASPE Project Officers, Laurel Fuller and D.E.B. Potter, at 

HHS/ASPE/DALTCP, Room 424E, H.H. Humphrey Building, 200 Independence Avenue, S.W., 

Washington, D.C. 20201; Laurel.Fuller@hhs.gov.

The opinions and views expressed in this report are those of the authors. They do not reflect the 

views of the Department of Health and Human Services, the contractor or any other funding 

organization. This report was completed and submitted on September 29, 2017.

i

TABLE OF CONTENTS 

ACKNOWLEDGMENTS .................................................................................................................................. v

EXECUTIVE SUMMARY ................................................................................................................................ vi

INTRODUCTION ............................................................................................................................................ 1

Epidemiology of Substance Use and Substance Use Disorders in the United States................................ 2

Substance Use Disorder Treatment Access and Uptake in the United States .......................................... 7

Initiation and Engagement in Treatment ................................................................................................ 20

Initiation and Engagement Measures...................................................................................................... 20

Interventions Designed to Improve Initiation and Engagement............................................................. 26

STUDY OBJECTIVES AND HYPOTHESES ...................................................................................................... 36

METHODS ................................................................................................................................................... 37

Quantitative Methods ............................................................................................................................. 37

Qualitative Methods................................................................................................................................ 47

RESULTS ...................................................................................................................................................... 52

Quantitative Results ................................................................................................................................ 52

Qualitative Results................................................................................................................................... 71

SYNTHESIS OF FINDINGS AND STUDY IMPLICATIONS............................................................................... 94

Individual Influences on SUD Treatment Participation ........................................................................... 94

Provider Influences on SUD Treatment Participation ............................................................................. 96

Market and Environmental Influences on SUD Treatment Participation................................................ 97

Health Plan Influences on SUD Treatment Participation....................................................................... 100

Study Limitations................................................................................................................................... 105

CONCLUSION ............................................................................................................................................ 107

REFERENCES.............................................................................................................................................. 109

APPENDICES

APPENDIX A. Glossary and Acronyms................................................................................................A-1

APPENDIX B. Opioid, Alcohol, and Other Substance Use Disorder Diagnoses ................................A-10

APPENDIX C. Algorithm for Identifying Members with Alcohol or Other Substance 

Use Disorders..............................................................................................................A-13

APPENDIX D. Site Visit Discussion Guide..........................................................................................A-14

APPENDIX E. List of Nodes Used for Qualitative Coding..................................................................A-36

APPENDIX F. Deidentified Summaries of Health Plan Visits............................................................A-37
ii

LIST OF FIGURES AND TABLES 

FIGURE 1. Theoretical Model to Explain Participation in Substance Use Disorder 

Treatment .............................................................................................................................. 9

FIGURE 2. IET for Commercial HMO and PPO Plans, 2005-2014.......................................................... 24

FIGURE 3. IET for Medicaid HMO Plans, 2005-2014 ............................................................................. 25

FIGURE 4. IET for Medicare HMO and PPO Plans, 2005-2014.............................................................. 26

FIGURE 5. Tripartite Mixed Methods Study Design .............................................................................. 37

FIGURE 6. Initiation Rate Calculation Process....................................................................................... 41

FIGURE 7. Engagement Rate Calculation Process................................................................................. 42

FIGURE 8. Health Plan Site Visit Selection Process............................................................................... 49

FIGURE 9. Spectrum of Governance Structures and Factors Affecting Health Plan 

Organization......................................................................................................................... 72

FIGURE 10. Quality Improvement Activities Used by Health Plans........................................................ 77

FIGURE E.1. Coding Tree for Qualitative Coding...................................................................................A-36

TABLE 1. Summary of 30-Day Prevalence Rates of Substance Use and Annual 

Prevalence Rates of Dependence or Abuse of Alcohol and Illicit Drugs 

Among People Aged 12 Years and Older in 2015 .................................................................. 2

TABLE 2. Alcohol Use and Disorder Prevalence in 2015 by Selected Demographic 

Characteristics........................................................................................................................ 3

TABLE 3. Illicit Drug Use and Disorder Prevalence in 2015 by Selected Demographic 

Characteristics........................................................................................................................ 4

TABLE 4. Percentages of Heroin Use Disorders and Past-Year Heroin Use Over Time......................... 5

TABLE 5. Prescription Opioid Misuse and Disorder Prevalence in 2015 by Selected 

Demographic Characteristics................................................................................................. 6
iii

TABLE 6. Themes from Multisite Improvement Efforts to Enhance Initiation and 

Engagement ......................................................................................................................... 31

TABLE 7. Number of Employer Health Plans with more than 10, 20, 30, and 50 

Beneficiaries Meeting the Denominator Criteria for the IET Measure,

Overall and Limited to Those with OUDs, 2013-2014.......................................................... 39

TABLE 8. Outcome Variables............................................................................................................... 40

TABLE 9. Covariates............................................................................................................................. 43

TABLE 10. Characteristics of Employer Health Plans Included in the Analysis of NCQA 

IET Measures for SUD Treatment......................................................................................... 53

TABLE 11. Mean NCQA IET Measures for SUD Treatment by Employer Health Plan 

Characteristics...................................................................................................................... 54

TABLE 12. Employer Health Plan Characteristics by Performance on the NCQA 

Initiation Measure for SUD Treatment ................................................................................ 57

TABLE 13. Employer Health Plan Characteristics by Performance on the NCQA 

Engagement Measure for SUD Treatment........................................................................... 58

TABLE 14. Multivariate Regression Results Examining the Effect of Health Plan and 

Environmental Characteristics on Employer Health Plan Performance on 

the NCQA IET Measures for SUD Treatment........................................................................ 59

TABLE 15. Characteristics of Employer Health Plans Included in the Analysis of NCQA 

IET Measures, Limited to OUDs ........................................................................................... 61

TABLE 16. Mean NCQA IET Measures by Employer Health Plan Characteristics, Limited 

to OUDs................................................................................................................................ 62

TABLE 17. Employer Health Plan Characteristics by Performance on the NCQA 

Initiation Measure, Limited to OUDs ................................................................................... 66

TABLE 18. Employer Health Plan Characteristics by Performance on the NCQA 

Engagement Measure, Limited to OUDs.............................................................................. 68

TABLE 19. Multivariate Regression Results Examining the Effect of Health Plan and 

Environmental Characteristics on Employer Health Plan Performance on 

the NCQA IET Measures, Limited to OUDs........................................................................... 69

TABLE A.1. Glossary of Terms and Definitions......................................................................................A-1

TABLE A.2. Definitions of Acronyms and Abbreviations .......................................................................A-8
iv

TABLE B.1. OUD Diagnoses..................................................................................................................A-10

TABLE B.2. Alcohol and Other SUD Diagnoses....................................................................................A-11

TABLE C.1. Algorithm for Identifying Members with Alcohol or Other SUDs.....................................A-13

TABLE D.1. Site Visit Agenda ...............................................................................................................A-15

TABLE D.2. Interviewer/Notetaking Process.......................................................................................A-34

TABLE D.3. Template for Site Visit Notes ............................................................................................A-35

TABLE F.1. Site Visit Interviewees for Health Plan ID 2010 ................................................................A-37

TABLE F.2. Site Visit Interviewees for Health Plan ID 2006 ................................................................A-40

TABLE F.3. Site Visit Interviewees for Health Plan ID 2003 ................................................................A-44

TABLE F.4. Site Visit Interviewees for Health Plan ID 9522 ................................................................A-48

TABLE F.5. Site Visit Interviewees for Health Plan ID 8200 ................................................................A-51

TABLE F.6. Site Visit Interviewees for Health Plan ID 4019 ................................................................A-54
v

ACKNOWLEDGMENTS 

Truven Health Analytics, an IBM company, prepared this report under contract to the Office of 

the Assistant Secretary for Planning and Evaluation (ASPE), U.S. Department of Health and 

Human Services (HHS) (HHSP23320100022WI/HHSP23337006T). The authors appreciate the 

guidance of D.E.B. Potter, Laurel Fuller, and Alexis Horan (ASPE). Richard Bizier and Timothy L. 

Bullock (Truven) contributed to the data programming and analysis. Paige Jackson, Lucy Karnell, 

and Linda Lee (Truven) provided editorial support. Shirlene T Harris and Quita Mullan provided 

assistance with appendix preparation. Mustafa Karakus and Brian Burwell (Truven) provided 

feedback on this report and guidance throughout the project. Pamela Greenberg and Mady 

Chalk provided additional assistance.

The views and opinions expressed here are those of the authors and do not necessarily reflect 

the views, opinions, or policies of ASPE or HHS. The authors are solely responsible for any 

errors.
vi

EXECUTIVE SUMMARY 

Background 

In 2015, 20.8 million people aged 12 years or older (7.8 percent of the United States

population) had a substance use disorder (SUD) in the previous year.1 Approximately 75 

percent of this group, or 15.7 million Americans, had an alcohol use disorder,12.0 million had a 

prescription opioid use disorder (OUD),2and about 0.6 million had a heroin use disorder.1 Since 

1999, opioid-related overdose deaths in the United States have quadrupled, with more than 

15,000 individuals experiencing prescription drug-related overdose deaths in 2015.3 Even 

though evidence-based SUD treatments are effective, rates of treatment receipt are quite low. 

In 2015, only 18 percent of the population with SUDs, or 3.7 million people, received SUD 

treatment--a number that has not increased significantly since 2002.1,4 Only about 48 percent 

of patients who enter SUD treatment actually complete it.5

SUD TREATMENT ACCESS

In 2015, only 18% of the population with SUDs received treatment--a number 

that has not increased significantly since 2002. For the definition of SUD and 

other key terms, see Table A.1. Glossary of terms and definitions. Terms and 

Definitions.

One measure of treatment receipt is the Initiation and Engagement of Alcohol and Other Drug 

Dependence Treatment (IET) performance measure, which is commonly reported by health 

plans and used by health systems and Medicaid and Medicare programs. Reported rates of 

initiation and engagement vary significantly among health plans, and national rates of initiation 

and engagement have not improved over time. This variation indicates that some plans are 

more effective than others at initiating and engaging their members in SUD treatment.6

In response to the stagnating rates of initiation and engagement, the U.S. Department of Health 

and Human Services Office of the Assistant Secretary for Planning and Evaluation initiated a 

study to determine how higher-performing health plans improve initiation and subsequent 

engagement in SUD treatment. Previous research has shown that many variables may 

contribute to patients’ initiation and engagement in treatment, including individual, provider, 

health plan, and market and environmental factors. This study examines how these factors 

affect health plan performance on the IET measures for both commercial and Medicaid health 

plans and how initiation and engagement may be improved.
vii

Study Objectives and Hypotheses 

This study has two overarching objectives: 

 Determine the models of care, quality improvement interventions, and best practices 

used by higher-performing health plans to improve initiation and engagement in SUD 

treatment.

 Describe the provider, beneficiary, and market factors that affect their ability to 

successfully initiate and engage beneficiaries in substance use treatment services.

On the basis of existing literature, the research team hypothesized that health plans that 

performed well on the IET measures would be highly integrated behavioral and physical health 

service models; they would reimburse for a variety of substance use treatment-related services 

including case management, routine outreach, peer supports, outpatient, inpatient, partial 

hospitalization, and residential treatment; they would have high network adequacy and provide 

financial incentives for providers; and they might be more likely to serve smaller markets in a 

community-oriented model rather than be plans with large beneficiary enrollment covering 

diverse populations and geographic areas.

Methodology 

To determine factors that contribute to health plan success in engaging plan members in SUD 

treatment, we used a sequential, explanatory mixed methods study design where quantitative 

data were analyzed before qualitative data were collected, to help explain results observed in 

the quantitative analyses. We initially conducted an environmental scan to provide background 

on: (1) the epidemiology of substance use, SUDs, and treatment; (2) factors associated with 

treatment initiation and engagement; (3) interventions designed to improve initiation and 

engagement; and (4) the development and use of the IET measure. The results of the scan 

informed both the quantitative and qualitative research that followed.

INITIATION AND ENGAGEMENT

We used the NCQA measure of IET in much of this study to define and 

measure initiation and engagement, which are two separate rates within the 

measure. A simplified definition of initiation is the percentage of members 

with an alcohol or other drug diagnosis who had at least one instance of 

treatment within 14 days of diagnosis. Engagement is the percentage of 

members who initiated and had at least two additional substance use 

treatment visits within 30 days of initiation.

For the quantitative analysis of factors associated with initiation and engagement among 

adults, we used the 2013 and 2014 Truven Health MarketScan® Commercial Claims and 

Encounters Research Database, linked to geographic information that provided state-level 
viii

market characteristics. The unit of analysis for this study was the employer health plan. We 

analyzed initiation and engagement rates for SUD treatment and for OUD treatment. We 

included 321 health plans in our analysis of the rates for SUD treatment, with a mean of 50,585 

beneficiaries, and 82 plans for the analysis of the rates for OUD treatment, with a mean of 

92,521 beneficiaries. Covariates examined in the quantitative analyses included those related 

to: (1) health plan structure; (2) reimbursement factors; (3) benefit design; (4) beneficiary 

characteristics aggregated to the plan level; and (5) state-level market and environmental 

characteristics. We calculated descriptive statistics separately, and we completed four 

multivariate regressions to examine the relationship between the selected covariates and the 

initiation and engagement measure outcomes. Separate analyses addressed initiation and 

engagement measure outcomes for SUD treatment and for OUD treatment.

For the qualitative research component, we selected potential health plans to study through 

interviews of their representatives. We chose these plans on the basis of their performance on 

IET and other behavioral health measures reported in National Committee for Quality 

Assurance (NCQA) Quality Compass data for commercial plan performance from January 1, 

2015, through December 31, 2015, and for Medicaid plan performance from January 1, 2014, 

through December 31, 2014. The NCQA Healthcare Effectiveness Data and Information Set 

measure data capture at least 75 percent of health plans in the United States. Outreach to topranked plans resulted in six site visits--one with a commercial plan and five with Medicaid plans.

To guide the health plan interviews, we developed a site visit protocol and semi-structured 

discussion guide. Research team members conducted qualitative, semi-structured group 

interviews with health plan staff and affiliates in spring 2017. Interviews were analyzed using a 

thematic framework analysis approach in combination with more inductive strategies to enable 

novel themes to emerge within the analysis.

Quantitative Results 

The quantitative multivariate analyses indicated that, among other findings, higher rates of SUD 

treatment initiation were associated with providing higher numbers of intensive outpatient 

(IOP) and partial hospitalization services per beneficiary (β = 2.06408, p = 0.0103). Results also 

suggested that having higher out-of-pocket costs for outpatient SUD services per user may be 

associated with higher rates of SUD initiation per beneficiary (β = 0.000517, p = 0.0007). Higher 

rates of SUD engagement were associated with similar characteristics, specifically providing 

higher numbers of IOP and partial hospitalization services per beneficiary (β = 3.82326, 

p <0.0001) and higher numbers of SUD outpatient services per beneficiary (β = 4.13869, 

p <0.0001). Higher rates of engagement were negatively associated with having more 

beneficiaries in the plan with an identified SUD (β = -12.6598, p = 0.0001) and more 

beneficiaries who are female (β = -0.20293, p = 0.0497). 

Characteristics associated with higher rates of initiation of OUD treatment included providing 

higher numbers of IOP and partial hospitalization services per beneficiary (β = 4.47344, 
ix

p = 0.0409) and being in a state with a higher prevalence of opioid prescriptions relative to the 

state population (β = 0.00228, p = 0.024). Higher rates of engagement were associated with 

providing higher numbers of SUD IOP and partial hospitalization services per beneficiary (β = 

4.07017, p = 0.0001). Higher engagement was negatively associated with, for example, having 

a higher percentage of beneficiaries with an identified OUD (β = -10.549, p = 0.0089) or a higher 

percentage of beneficiaries who are female (β = -0.1958, p = 0.0233). 

Qualitative Results 

Representatives from six health plans participated in interviews. The plans served 

geographically diverse populations across the United States, and all were ranked in the top 5 

percent (nationally) for performance on initiation and/or engagement rates using the IET

measure. The intent was to have a mix of commercial and Medicaid plans; ultimately 

representatives from one commercial and five Medicaid plans participated in the study.

HEALTH PLAN STRUCTURE

Some level of local decision-making is critical to implementing behavioral 

health policies and procedures in ways that respond to local population 

needs, whether the plan is small and local or large and national.

Governance and structure. Our interviews included representatives of large and small health 

plans. Representatives of smaller, locally governed plans described the importance of a “feet 

on the street” approach, whereas interviewees from a national insurance company with a 

centralized corporate leadership felt that their approach enabled them to streamline decisionmaking and ensure consistency across business lines. For all but the smallest plan, however, 

interviewees typically described a multilevel governance approach, including corporate and 

local oversight of behavioral health care, although the extent of plan emphasis on local 

governance represented a spectrum. Because these were all higher-performing plans, it is 

impossible to determine whether one approach more consistently translates into improved 

initiation or engagement. A locally focused approach may be one of the ways that the selected 

plans differentiate themselves from others that may fare more poorly on initiation and 

engagement, if lack of local governance and local initiatives are more limited among the latter. 

Interviewees also highlighted the importance of regular communication between plan levels 

and between different groups within plan levels regarding beneficiary needs or challenges to 

accessing health services.

Care model and culture. Interviewees from every health plan described their plan’s care model 

and culture as integral to their success with initiating and engaging beneficiaries in treatment. 

Care models were described as focused on care coordination, including coordination of 

physical, mental, behavioral, and substance-use-specific services. All health plan 

representatives described their case managers, care coordinators, and community health 

workers as promoting beneficiaries’ use of services included within the plan’s benefit array. 
x

Health plan leadership and contracting staff also described efforts to convey the health plan’s 

mission statement when meeting with new providers to reinforce the plans’ commitment to

continuous engagement with beneficiaries, knowing that beneficiary receptiveness will vary 

over time.

Benefit design. Health plan interviewees described significant differences in their plan benefit 

arrays. All plans cover outpatient treatment services without prior authorization. All cover 

medically monitored and medically managed detoxification services, often requiring prior 

authorization or notification, but one only covers these services for pregnant women.

A ROLE FOR PRIOR NOTIFICATION

Prior notification may play a role in allowing health plans to coordinate care 

and ensure follow-up after hospitalization or detoxification by alerting the 

plan to the patient’s admission in a timely fashion. 

Inpatient, IOP, and partial hospitalization services frequently require prior authorization. 

Coverage of peer and recovery support services was sparse among Medicaid plans. The 

commercial plan provides members access to peer supports as part of their “service buffet” 

offered at all affiliate SUD treatment clinics. All health plans provide members with coverage of 

at least two medication-assisted treatment (MAT) options and cover naloxone. Most 

representatives do not require prior authorization for MAT.

Representatives of Medicaid plans described limitations on their ability to reimburse for 

residential treatment services because of state Medicaid policy, with four of the five 

interviewees indicating that their (four separate) state Medicaid agencies did not include 

residential treatment in Medicaid benefits for non-pregnant beneficiaries. The one Medicaid 

plan with a residential treatment benefit was able to approve only limited residential services. 

Conversely, the commercial plan reported residential services as a covered benefit. 

None of the Medicaid plans required beneficiaries to pay for covered services out-of-pocket. 

The commercial plan representative described their benefit array as an “all you can eat buffet” 

of services, free of prior authorization or utilization management review but requiring payment 

of a deductible. 

Quality improvement. Health plan interviewees reported investing significant resources in 

quality improvement activities, expressing a concern that poorly managed SUDs would result in 

higher overall costs for the plan as well as inadequate care for beneficiaries. Quality 

improvement efforts include developing new staff positions to support activities, investing in 

software to develop data analytic capabilities, and facilitating secure communications with 

beneficiaries and providers. To maximize returns, two of the Medicaid plans reported focusing 

their time and financial investments on initiatives that targeted activities related to quality 

measures for which they were financially at risk under the state Medicaid plan. Types of quality 

improvement initiatives vary, in part because of the different levels of resources available to 

plans.
xi

All representatives described open communication within the plan and between the plan and 

their membership or providers as key to achieving improvements in SUD treatment. 

Communication strategies included using secure electronic messaging services to maintain realtime communication with providers. Outreach teams are trained on effective communication 

techniques to encourage members to engage in treatment. Health plan interviewees expressed 

a substantial interest in maintaining communication between physical health and behavioral 

health providers. Some interviewees also described co-locating behavioral health counselors in 

primary care practices as critical to treatment initiation for patients who would not attend 

services provided in a behavioral health facility.

HEALTH PLAN MEMBERS AT MODERATE RISK OF SUD

Health plans are increasingly using data analytics to identify members 

misusing opioid prescriptions, enabling outreach to and treatment for 

individuals who may not have any previous indicator of risk.

Barriers affecting health plan initiation and engagement rates. Health plan interviewees 

described several factors that influence their plans’ effectiveness at initiating and engaging 

members in substance use treatment services.

Federal and state policies were identified as major factors affecting health plans’ ability to 

provide comprehensive services to meet membership needs. Interviewees described federal 

confidentiality requirements of 42 Code of Federal Regulations (CFR) Part 2 as challenging to 

coordinating care for members admitted to detox and other inpatient facilities. Health plan 

stakeholders described learning of beneficiary detox admissions only after the beneficiary had 

been discharged. Another federal policy they mentioned was the restriction on Medicaid 

coverage of care in Institutions for Mental Diseases (IMD), which precludes Medicaid 

reimbursement for residential facilities with more than 15 beds, although some states are 

obtaining Section 1115 waivers to allow reimbursement for residential care.

Representatives from each of the five Medicaid plans also identified policies emanating from 

their state Medicaid agency as factors limiting their ability to initiate and engage members in 

SUD treatment. They viewed restrictions on the types of services included in the state 

Medicaid benefit array, such as for residential treatment or peer and recovery supports, as a 

substantial barrier. Some expressed a desire to cover additional treatment services not 

reimbursable by the state, but ultimately felt doing so was beyond their financial capabilities. 

Medicaid plan representatives said that state Medicaid policies allowing beneficiaries to switch 

plans negatively affected their ability to coordinate services or meaningfully use pharmacy or 

prescriber lock-in programs. A few representatives described placing beneficiaries in lock-in 

programs to monitor their prescription use while conducting outreach and case management 

efforts, only to have the beneficiary switch mid-year to another plan. Similarly, plan inability to 

access Prescription Drug Monitoring Program (PDMP) data prevents plans from learning if 

beneficiaries are evading lock-ins by paying for controlled substances with cash.
xii

All health plan representatives explained that network adequacy for SUD treatment services 

was a current concern and a major barrier to future access to treatment. Although each of the 

health plans is meeting network requirements set by the state Medicaid agency and their 

governance boards, interviewees repeatedly described having additional network needs. First, 

the growing need for treatment coincides with decreases in the number of substance use 

providers. Second, there is limited access to Drug Addiction Treatment Act of 2000-waivered 

buprenorphine prescribers willing to treat Medicaid beneficiaries. Third, prescribers often will 

not take Medicaid beneficiaries because of preconceived notions about that population, or 

because they accept only cash for services. Fourth, in addition to reimbursement constraints, 

there is a lack of beds available in residential treatment facilities. Fifth, low reimbursement 

rates limit plans’ ability to recruit providers to their network and expand network adequacy for 

necessary services, and ultimately to ensure access to care. Providers withhold open spots 

from Medicaid beneficiaries to receive greater reimbursement from commercial plans and 

individuals paying out-of-pocket.

COMBATING STIGMA & IMPROVING CARE COORDINATION

Co-location of SUD counseling and other services with primary care reduces 

the stigma of accessing a facility identified as treating SUDs, catches members 

in locations where they are more comfortable, and permits improved 

coordination between physical and behavioral health care.

Stigma around substance use and behavioral health treatment repeatedly was cited as a barrier 

to treatment, hindering effective initiation and engagement. Stigma may manifest in patients, 

their families, their communities, and providers. Interviewees reported supporting community 

education about SUDs and the positive impact of treatment as ways to reduce stigma in the 

community and among those who might need treatment. They also described investing 

resources in reducing provider stigma related to SUDs. Interviewees also said that providers 

often hesitate to conduct substance use risk screenings because they had not received 

adequate addiction training and were uncertain about how to speak with their patients about 

such issues.

Plan members are not always ready to abstain from substance use or other related risk 

behaviors, which may result in unwillingness to initiate traditional substance use treatment. 

Health plans are more frequently promoting harm reduction techniques and “no wrong door” 

and “no wrong time” approaches to engage members in SUD treatment.

Interviewees also described plan members’ competing priorities such as housing, child care, 

and accessing treatment for comorbid physical and behavioral health conditions as factors 

affecting initiation or engagement in SUD treatment services. They identified beneficiaries who 

are homeless or transient as challenging to engage because they do not have stable addresses 

or phone numbers to maintain outreach. They described efforts to provide members with 

transportation to follow-up appointments as a means of ensuring attendance. Despite being 
xiii

able to offer these supports, case managers indicated that beneficiaries’ attendance at followup appointments still was impeded by competing demands.

Discussion 

The opioid epidemic has worsened a pre-existing failure to provide SUD treatment to many 

people in the United States who desperately need it. Many of those in need of treatment do 

not attempt to access it, and many who try find access difficult or impossible. The aim of this 

study was to determine how some health plans successfully get beneficiaries into SUD 

treatment and keep them there. Our environmental scan identified many potential influences 

on initiation and engagement, falling into the four categories of individual, provider, 

environmental or market, and health plan factors. Our quantitative analyses linking 

beneficiary, plan, and market characteristics to commercial health plans, as well as subsequent 

semi-structured interviews with high performing plans, elucidated a variety of key influences, 

many of which are summarized above.

Individual influences. The literature indicates that many individual influences can affect 

initiation and engagement. Among those influences, some, including the individual’s sex,7,8,9,10

co-occurring conditions,11 and stigma,12 were addressed in the quantitative or qualitative 

components of this study. The literature indicates that being female decreases the likelihood of 

treatment participation.7,8,9,10 Our quantitative research indicated that plans with larger 

percentages of females are less likely to do well on the engagement rate, and our qualitative 

research allowed us to elaborate on why (e.g., competing needs such as child care and 

transportation). Some successful plans have implemented initiatives designed to address these 

needs, but effects of these efforts were mixed. The qualitative part of this study also identified 

ways in which plans seek to better integrate SUD and mental health treatment and to address 

stigma among patients, families, communities, and providers. It seems that efforts to integrate 

care, co-locate services, and provide education all can help alleviate stigma and address 

conditions that co-occur with SUD.

Provider influences. Consistent with previous research, health plan interviewees reported that 

provider expertise,13,14,15 attitudes,16 and shortages17,18,19 can influence treatment initiation and 

engagement, and they described steps plans have taken to address problems in these areas. 

These include efforts aimed at improving expertise and comfort and decreasing provider stigma 

about individuals with SUDs. However, at least one plan representative expressed hesitation 

about developing provider-focused initiatives such as educational activities for fear of 

overwhelming providers with information on new initiatives, tools, and other SUD-related 

information. Interestingly, such plans may focus quality improvement efforts more extensively 

on patients than on providers. Most take both approaches. Within the qualitative sample of 

only six high performing plans, however, neither approach stood out as particular to the plans 

with the highest performance.
xiv

Efforts to address provider expertise and attitudes should somewhat alleviate provider 

shortages. Although plan representatives described outreach and other approaches to induce 

providers into their networks, solving the problem of provider shortages is not simple. 

Shortages of individual providers such as addiction specialists, psychiatrists, and buprenorphine 

prescribers, as well as of residential treatment, detox facilities, or opioid treatment programs, 

combine to make access to the right level of care at the right time difficult for many plan 

beneficiaries.

Market and environmental influences. The qualitative part of this study most clearly identified 

market and environmental factors that influence SUD treatment initiation and engagement, 

some of which are addressed in previous literature. Health plan interviewees identified both 

federal and state policies that can be barriers to initiation and engagement. The two primary 

perceived federal impediments were: (1) the regulation at 42 CFR Part 2, which may be met 

with prior authorization requirements or efforts to build relationships with facilities; and (2) the 

IMD restriction on reimbursement, which now may be ameliorated with a Section 1115 

waiver.20 State policies that prevent plans from accessing PDMP data or that allow 

beneficiaries to switch plans easily were seen as impeding the effectiveness of pharmacy lockins. State Medicaid plans that do not reimburse for certain services,21,22 such as peer or 

recovery supports, or state Medicaid programs with budgetary problems that result in low or 

delayed reimbursement,18 can impede the ability of Medicaid plans to engage providers and 

serve their beneficiaries. Plans struggle with the repercussions of these policies, trying to find 

ways to serve their beneficiaries while accommodating the policy or law.

Health plan influences. Health plans take many approaches to improving initiation and 

engagement in SUD treatment. Health plan structure; benefit design and 

reimbursement;

21,22,23,24,25 network adequacy; and the culture of care and approach to care 

integration, coordination, and management26,27 all play roles in how health plans influence 

initiation and engagement. Quantitative and qualitative analyses identified organizational 

interventions as factors in increasing treatment uptake. The health plan staff members we 

interviewed were invested in a variety of quality improvement initiatives at both the enterprise 

and local plan level, including initiatives with providers and beneficiaries and internal plan 

initiatives such as data mining and communication strategies. The plans viewed these quality 

improvement initiatives as important to further treatment access, to improve the quality of 

care, and, given the high costs that can be associated with undertreated SUDs, to conserve 

resources.

Implications. This study has many implications, which include the following:

1. Expanding treatment options to cover the care continuum, including peer and recovery 

specialists, may help provide access to care when it is needed and at the level most 

relevant to a particular patient. Among other things, expanding Section 1115 waivers to 

allow Medicaid reimbursement of residential treatment may have the secondary effect 

of increasing the number of residential placements available for everyone.
xv

2. Finding ways to either modify or provide better education regarding 42 CFR Part 2 could 

assist plans in their efforts to enhance care coordination and follow-up. Allowing plans 

access to PDMP data will provide them with better information about their 

beneficiaries’ access to controlled substances.

3. Various aspects of health plan structure such as size, decision locus, and communication 

strategies play an apparent role in the health plans’ ability to ensure treatment initiation 

and engagement. These same factors also may play a role in follow-up after 

hospitalization or emergency department visits and in other care coordination efforts. 

Better understanding of the influence of these factors in lower-performing plans will be 

important as we move to a health care system that is more coordinated and integrated 

across settings and disciplines.

4. Making certain that there are mechanisms to pay for care coordination and 

management, as well as cross-system integration, will be important to improve SUD 

treatment initiation and engagement.

5. Finding ways to encourage co-location of behavioral and primary care services--where 

there can be a warm hand-off, where stigma is reduced, and where varied services are 

close by--will help increase initiation and engagement, as well as integrate SUD 

treatment into the general health care system.

6. By addressing human needs that compete with treatment, we also may be able to 

address initiation and engagement differences between men and women, as well as 

treatment disparities related to socioeconomic differences.

7. By addressing workforce shortages, adequacy of reimbursement, and provider stigma, 

we may help alleviate some of the provider shortages described in the study. By finding 

ways to incentivize providers not to require cash payment, additional providers may be 

brought into payer networks.

8. Researchers and policymakers should consider whether alternative approaches to 

measuring network adequacy can help maximize health plan networks when provider 

shortages create an obstacle.

9. When there are financial incentives for health plans, those plans tend to focus quality 

improvement efforts on the metrics for which they may be paid. This can have 

repercussions for beneficiary care, and the metrics should be selected carefully.

Study limitations. Like all studies, this one has limitations. First, the rapid change that has 

taken place in recent years in health care means that health plans identified for potential 

interviews on the basis of 2014 results on the IET measure were somewhat different when staff 

members were interviewed in 2017. Both IET rates and plan strategies for improving SUD 

treatment participation may have continued, grown, or decreased. Second, the quantitative 
xvi

analyses used commercial insurance data, whereas the qualitative interviews were primarily 

with Medicaid plans. Although this represents a difference between the quantitative and 

qualitative aspects of the study, it may provide the benefit of balancing the information 

gathered. Third, some variables used in the quantitative analyses may not have completely 

captured the sort of information that was intended. For example, some of the market and 

environmental variables intended to indicate level of state support for SUD treatment may be 

an imperfect proxy for market or policy realities.

Conclusion. Identifying mechanisms to enhance SUD treatment initiation and continued 

engagement in care is a public health priority. As both administrators and coordinators of 

health care benefits, health plans are positioned to play a crucial role in mitigating potential 

access barriers and developing mechanisms that bring beneficiaries into care and keep them 

there. Understanding the role that health plans can play, as well as the role that other factors 

have in health plans’ ability to improve SUD treatment initiation and continued engagement, is 

important to facilitate improvement in care increasingly reimbursed by these private 

organizations.

For the reader’s convenience, we include a glossary of some terms used in this report and a list 

of common acronyms and abbreviations in Table A.1 and Table A.2.
1

INTRODUCTION 

The 2015 National Survey on Drug Use and Health (NSDUH) found that 20.8 million people aged 

12 years or older (7.8 percent of the United States population) had a substance use disorder 

(SUD) in the previous year.1 Evidence-based SUD treatments such as behavioral therapies and 

medication are effective, as evidenced by hundreds of rigorous efficacy trials and millions of 

individuals in recovery. However, despite the great need for and efficacy of these treatments, 

rates of treatment receipt are extremely low. In 2015, only 3.7 million people received SUD 

treatment--a number that has not increased significantly since 2002.1,4 Moreover, once 

individuals enter treatment, they tend to drop out before obtaining meaningful benefits. Only 

about 48 percent of patients who enter SUD treatment actually complete it,5even as research 

has shown that engagement in treatment improves treatment outcomes.28

Among other initiatives, one way that federal, state, and privately funded health care systems

have tried to address the low rates of initiation and engagement in SUD treatment is through 

performance metrics. Federal, state, and private payers have incorporated measures endorsed 

by the National Quality Forum into their programs to track performance among health plans. 

One such performance measure is Initiation and Engagement of Alcohol and Other Drug 

Dependence Treatment (IET).

SUD TREATMENT ACCESS

In 2015, only 18% of the population with SUD received treatment--a number 

that has not increased significantly since 2002.

The rate of IET varies significantly among health plans, suggesting that some plans are more 

effective at initiating and engaging their members in SUD treatment than others.6 Overall 

national rates of initiation and engagement have not shown consistent improvement over time. 

In commercial and Medicaid health plans, respectively, rates for initiation have hovered 

between 39.1 percent and 49.0 percent, and rates of engagement have stayed between 9.6 

percent and 16.2 percent throughout the past decade, with no sustained improvement.29

In response to the stagnating rates of initiation and engagement, the U.S. Department of Health 

and Human Services (HHS) Office of the Assistant Secretary for Planning and Evaluation (ASPE) 

initiated a study to determine how higher-performing health plans improve initiation and 

subsequent engagement in SUD treatment. This report synthesizes the results of quantitative 

analyses of commercial health plan data and qualitative interviews with Medicaid and 

commercial plans, to determine health plan and other factors that influence initiation and 

engagement in SUD treatment. We provide background gleaned from the literature, address 

the methods for both the quantitative and qualitative analyses, present the results of that 

research, and offer a synthesis of the findings, including an overview of health plan and related 

factors that influence initiation and engagement. 
2

Epidemiology of Substance Use and Substance Use Disorders in the United States 

Substance use and SUDs are a persistent public health concern. The 2015 NSDUH found that 

approximately 138.3 million Americans aged 12 years or older reported past 30-day use of 

alcohol, and 27 million reported past 30-day use of illicit drugs (Table 1).1 National prevalence 

rates also are high for SUDs. Approximately 20.8 million Americans aged 12 years or older were 

classified with an SUD in 2015. Among those identified, 7.7 million had an illicit drug use 

disorder; 15.7 million had an alcohol use disorder; and 2.7 million were diagnosed with both an 

alcohol and an illicit drug SUD (Table 1).1 Individuals aged 18-25 years had the highest rates of 

SUDs in 2015, with 18.2 percent of that age group having an SUD in the past year.2 A separate 

study that examined rates of SUDs in older adults estimated that, by 2020, approximately 5.7 

million adults aged 50 years and older will have an SUD.30 

TABLE 1. Summary of 30-Day Prevalence Rates of Substance Use and

Annual Prevalence Rates of Dependence or Abuse of Alcohol and Illicit Drugs

Among People Aged 12 Years and Older in 2015

Substance

Use in the Past 30 Days Dependence or Abusea

N

(in millions)

% of

population

N

(in millions)

% of

population

Any substance --- --- 20.8 7.8

Alcohol 138.3 51.7 15.7 5.9

Illicit drug 27.1 10.1 7.7 2.9

Alcohol and illicit drug --- --- 2.7 1.0

SOURCE: 2015 NSDUH.1

a. The 2015 NSDUH still used the terms abuse and dependence rather than the umbrella term 

substance use disorder with gradations of severity that was adopted in the Diagnostic and 

Statistical Manual of Mental Disorders, 5th Edition (DSM-V). Whenever this report 

provides information from the 2015 NSDUH that specifies abuse or dependence, the report 

uses those terms. If the NSDUH provided less granular information about disorders 

generally, this report refers to substance use disorders.

Epidemiology of Alcohol Use and Alcohol Use Disorders

Alcohol use, including binge drinking and heavy alcohol use, is common in the United States. 

Approximately 138.3 million Americans aged 12 years or older reported past 30-day use of 

alcohol in 2015.1 Approximately 66.7 million people, or one in four individuals aged 12 years or 

older in 2015, engaged in past 30-day binge drinking, with binge drinking defined as four or 

more drinks on one occasion for females and five or more drinks for males.1 Heavy alcohol use, 

which is defined as binge drinking on 5 or more days in the past 30 days, was present in an 

estimated 17.3 million individuals aged 12 years or older, or 6.5 percent of the population, in 

2015.1 In that same year, approximately 15.7 million Americans had an alcohol use disorder.1
3

Alcohol use and alcohol use disorders are more pronounced in certain demographic groups, 

including individuals aged 18-25 and males, with rates of past-month alcohol use highest in the 

non-Hispanic White population and alcohol use disorders highest in Native Americans (Table 

2).1 There also is evidence that women’s rates of alcohol use are heavily influenced by 

pregnancy status. In 2015, approximately 54.8 percent of non-pregnant women of childbearing 

age (15-44 years old) consumed alcohol in the past month, whereas those who were pregnant 

had past-month drinking rates of 9.3 percent. Rates were highest (16.4 percent) among those 

in the first trimester, followed by the second (6.1 percent) and third (4.3 percent) trimesters.2

TABLE 2. Alcohol Use and Disorder Prevalence in 2015

by Selected Demographic Characteristics

Characteristics Past 30-Day 

Alcohol Use, %

Alcohol Use 

Disorder, %

Binge 

Drinking, %

Heavy Alcohol 

Use, %

Age, years

12-17 9.6 2.5 5.8 0.9

18-25 58.3 10.9 39.0 10.9

26 and older 55.6 5.4 24.8 6.4

Sex

Male 56.2 7.8 29.6 8.9

Female 47.4 4.1 20.5 4.2

Race/ethnicity

Non-Hispanic White 57.0 6.1 26.0 7.6

Non-Hispanic Black 43.8 4.9 23.4 4.8

Asian 39.7 3.2 14.0 2.2

Native Hawaiian or 

other Pacific Islander 33.8 5.4 17.8 3.0

American Indian and 

Alaska Native 37.9 9.7 24.1 4.7

Two or more races 42.8 6.2 22.9 6.8

Hispanic 42.4 6.4 25.7 4.8

SOURCE: 2015 NSDUH.2

Epidemiology of Illicit Drug Use and Illicit Drug Use Disorders

In 2015, approximately 27.1 million Americans reported past 30-day illicit drug use, including 

those who misused prescription medication. The prevalence rate for past 30-day illicit drug use 

corresponds to one in every ten Americans or about 10.1 percent of the United States

population.1 Demographic groups with the highest rates of recent illicit drug use included 

those aged 18-25 years, males, and individuals identifying as being of two or more races (Table 

3). Among these groups, there is evidence that women’s rates of illicit drug use may be heavily 

influenced by age. Approximately 12.5 percent of non-pregnant women of childbearing age 

(15-44 years) engaged in past-month illicit drug use. This percentage was nearly 50 percent 

higher than the percentage for the female population overall. Approximately 4.7 percent of 

pregnant women (15-44 years old) reported illicit drug use, with rates highest among those in 

the second trimester (6.4 percent).2
4

In 2015, 7.7 million Americans had an illicit drug use disorder, constituting nearly 3 percent of 

the population aged 12 years or older.2 It is estimated that 9.9 percent of the United States

population will develop a drug use disorder at some point during their lifetimes.31 The highest 

prevalence rates were in people between the ages of 18 and 25, males, and those identifying as 

of two or more races (Table 3).

TABLE 3. Illicit Drug Use and Disorder Prevalence in 2015

by Selected Demographic Characteristics

Characteristics Past 30-Day Illicit 

Drug Use, %

Illicit Drug Use 

Disorder, %

Age

12-17 years 8.8 3.4

18-25 years 22.3 7.2

26 years and older 8.2 2.1

Sex

Male 12.5 3.8

Female 7.9 2.0

Race/ethnicity

Non-Hispanic White 10.2 2.8

Non-Hispanic Black 12.5 3.5

Asian 4.0 1.2

Native Hawaiian or other Pacific Islander 9.8 4.5

American Indian and Alaska Native 14.2 4.1

Two or more races 17.2 4.9

Hispanic 9.2 3.0

SOURCE: 2015 NSDUH.2

Opioid use and opioid use disorders (OUDs), whether related to heroin or to prescription opioid 

use, are among the most problematic substance use trends in the United States today. Since 

1999, opioid-related overdose deaths in the United States have quadrupled, with more than 

15,000 individuals experiencing prescription drug-related overdose deaths in 2015.3 Evidence 

shows that, among those with commercial insurance, professional charges for OUD treatment 

rose by more than 1,000 percent from 2011 to 2015 (from $71.66 million to $721.80 million). 

Total annual charges in 2015 for a person diagnosed with an OUD were 556 percent higher than 

the average for all patients.32 

Heroin Use and Heroin Use Disorders

Rates of heroin use have increased in recent years, from a relatively stable rate of 0.2 percent 

of the population between 2002 and 2011 to 0.3 percent starting in 2012 (Table 4).1 In 2015, 

approximately 0.3 million Americans aged 12 years and older reported past-month heroin use, 

and about 828,000 people reported past-year use.1 The 2015 NSDUH, however, revealed a 

dramatic reduction in the rate of new heroin users aged 12 years or older. In 2013, an 

estimated 169,000 individuals began engaging in heroin use in the year prior to being 
5

interviewed, and this number increased to 212,000 in 2014. The incidence of new users in 

2015, however, decreased to 135,000. Past-year initiation rates also decreased as a percentage 

of past-year users (24.9 percent in 2013, 23.1 percent in 2014, 16.3 percent in 2015).2,33 Young 

adults aged 18-25 years are more likely than any other age group to use heroin. In 2015, 0.6 

percent of young adults aged 18-25 years reported past-year heroin use,1 with 57,000 initiating 

heroin use in 2015.2

The prevalence of heroin use disorders also has grown in recent years (Table 4). In 2015, about 

0.6 million people or 0.2 percent of the population aged 12 years or older had a heroin use 

disorder in the past year.1 This was a statistically significant increase from 2010, when 0.1 

percent of the population had a heroin use disorder.4 Young adults were more likely than any 

other age group to be dependent on heroin (0.4 percent in 2015).1 Past-year heroin use 

disorder prevalence among those aged 18-25 years was 585,000 in 2015 (Table 4).2 Among 

adults aged 26 years and older, the prevalence of heroin dependence or abuse was 430,000 in 

2015, or 0.2 percent of the population.2 

TABLE 4. Percentages of Heroin Use Disorders and Past-Year Heroin Use Over Time

Characteristic Age, 

Years 2002 2010 2011 2012 2013 2014 2015

Past-year 

heroin use 

12+ 0.2a0.2 0.2 0.3 0.3 0.3 0.3

18-25 0.4a0.6 0.7 0.8 0.7 0.8 0.6

Heroin use 

disorder

12+ 0.1 0.1 0.2 0.2 0.2 0.2 0.2

18-25 0.2a0.3 0.4 0.5 0.5 0.5 0.4

SOURCE: 2015 NSDUH.1

a. Significant at the 0.05 level compared with 2015.

Heroin use disorder rates have a strong, positive correlation with heroin-related morbidity and 

overdose deaths over time.34 Among individuals with SUDs, heroin users have the highest 

prevalence of hospitalization (a 30 percent annual rate between 2009 and 2013).35 As 

dependence rates have increased, so have rates of heroin-related overdoses. There were 

nearly 13,000 heroin overdose deaths in 2015.36 The increase in overdoses has affected 

individuals across a range of sociodemographic groups. Between 2010 and 2012, heroinrelated overdoses increased 86 percent to 102 percent for every age group. In 2012, males had 

a heroin-related overdose rate of 3.3 per 100,000, which was a 99 percent increase from 2010.

In 2015, males aged 25-44 years had the highest death rates at 13.2 per 100,000--an increase of 

22.2 percent from 2014.36 Women experienced a 110.9 percent increase in heroin-related 

overdoses between 2010 and 2012. Rates of heroin-related overdose also have increased for 

each racial group in recent years. For both the non-Hispanic White and Hispanic White 

populations, heroin-related overdoses increased by approximately 102 percent between 2010 

and 2012. The African-American community experienced an 89.3 percent increase in heroinrelated overdoses for the same time period.37
6

HEROIN-RELATED OVERDOSES

Between 2010 and 2012, heroin-related overdoses increased 86% to 102%.

Prescription Opioid Misuse and Disorders

In 2015, 3.8 million individuals aged 12 years or older in the United States (1.4 percent of the 

population) reported current misuse (non-medical use) of prescription opioids. The number of 

individuals who reported past-year prescription opioid misuse was 12.5 million or 4.7 percent 

of the population. In that year, hydrocodone medications were the most frequently misused 

category of prescription opioids--misused by 2.7 percent of those aged 12 years or older in 

2015--followed by oxycodone medications (1.6 percent). In 2015, a total of 2.1 million 

individuals initiated prescription opioid misuse, and 2.0 million individuals had a prescription 

OUD (both 0.8 percent of those aged 12 years or older).2 According to the NSDUH, the 

demographic groups with the highest prevalence of prescription opioid misuse in 2015 included 

young adults aged 18-25 years, males, and individuals identified as being two or more races. 

The NSDUH did not report rates of prescription OUD other than by age, with those aged 18-25 

years having the highest rates of such disorders (Table 5).

TABLE 5. Prescription Opioid Misuse and Disorder Prevalence in 2015

by Selected Demographic Characteristics

Characteristics

Past 30-Day 

Prescription Opioid 

Misuse, %

Prescription

OUD, %

Age

12-17 years 3.9 0.5

18-25 years 8.5 1.2

26 years and older 4.1 0.7

Sex

Male 5.3 --

Female 4.0 --

Race/ethnicity

Non-Hispanic White 4.8 --

Non-Hispanic Black 4.4 --

Asian 1.8 --

Native Hawaiian or other Pacific Islander 5.4 --

American Indian and Alaska Native 5.6 --

Two or more races 8.4 --

Hispanic 5.0 --

SOURCE: 2015 NSDUH.2

Nearly half of all opioid overdose deaths involve a prescription opioid. Such deaths have 

quadrupled since 1999 and, in 2015, more than 15,000 individuals experienced prescription 

drug-related overdose deaths.3 Rudd et al. (2016) examined trends in both heroin and 

prescription opioid-related overdose death rates across 28 states from 2010 through 2015.38 
7

Rates of death from synthetic opioids other than methadone increased and, although many of 

these deaths involved prescription opioids, the increase seems to have been driven by illicitly 

manufactured fentanyl. In 2015, death rates from non-methadone synthetic opioids were 

greatest in males aged 25-44 years.38

Substance Use Disorder Treatment Access and Uptake in the United States 

Evidence-based treatment can effectively help people recover from SUDs.39 Recent analyses 

indicate that the addition of a single substance abuse treatment facility in a county may be 

associated with declines in rates of drug-induced mortality and many types of violent and 

financially motivated crimes, with an additional treatment facility reducing social costs 

attributed to all crime by approximately $700,000 annually. SUD treatment also has been 

shown to result in meaningfully reduced rates of crime, with a 10 percent relative increase in 

the SUD treatment rate at an average cost of $1.6 billion yielding a crime reduction benefit of 

$2.5-$4.8 billion.40 Other studies show that, for every dollar spent on SUD treatment, four 

dollars are saved in other health care costs.12

Many Americans in need of SUD treatment do not receive it. According to the 2015 NSDUH, 

approximately 21.7 million or 8.1 percent of Americans aged 12 years or older were identified 

as needing SUD treatment.1 Yet in 2015, only 3.7 million Americans aged 12 years or older, or 

14.0 percent of the United States population that needed treatment, received any substance 

use treatment for any kind of problem related to substance use. Among the 21.7 million 

individuals who needed substance use treatment, only 2.3 million people (10.8 percent) 

received specialty treatment.1 According to the NSDUH, when substance use treatment was 

utilized, most individuals surveyed sought care in self-help groups (1.9 million) and outpatient 

rehabilitation programs (1.75 million). They less commonly obtained care in outpatient mental 

health centers, inpatient rehabilitation facilities, hospital-based inpatient programs, private 

doctor’s offices, or emergency departments.2 

DEATHS FROM ALCOHOL

Alcohol misuse and alcohol use disorders result in an estimated 88,000 deaths 

annually.

Alcohol misuse and alcohol use disorders result in an estimated 88,000 deaths annually,41 and 

excessive alcohol consumption is associated with adverse health and social consequences, 

including liver cirrhosis, certain cancers, fetal alcohol spectrum disorder, unintentional injuries, 

and violent behaviors.42 Individuals with an alcohol use problem represent a heterogeneous 

population, which necessitates the use of personalized treatment approaches such as 

medication and counseling.43 Medication-assisted treatment (MAT) incorporating 

pharmacotherapy and, ideally, psychosocial treatment, is an evidence-based treatment for 

alcohol use disorders; medications used include acamprosate, disulfiram, or naltrexone.44 In 

2015, 2.2 million people aged 12 years or older (0.8 percent of the population) received any 
8

type of past-year treatment for an alcohol use problem. Among these individuals, treatment 

was most commonly reported as occurring, non-exclusively, in self-help groups (57.5 percent), 

outpatient (33.5 percent) or inpatient (28.1 percent) rehabilitation facilities, outpatient mental 

health centers (26.6 percent), and inpatient hospitals (20.1 percent).a In 2015, approximately 

1.4 million individuals reported receipt of specialty treatment in the past year for an alcohol use 

problem. This figure represented only 8.2 percent of the nearly 16.4 million individuals 

reported to need treatment for an alcohol use disorder. In 2015, only 12.9 percent and 7.8 

percent of individuals who needed treatment and identified as non-Hispanic Black and nonHispanic White, respectively, received it.2

According to the NSDUH, in 2015, 22.4 percent and 17.4 percent of individuals receiving 

substance use treatment in the past year cited prescription opioid abuse or heroin use, 

respectively, as their reason for treatment.2 Treatment for OUDs, whether related to heroin 

use or prescription opioid misuse, is critical. In addition to the devastation caused by overdose, 

opioid use can have other serious consequences. For example, a longitudinal study examining 

the 27-year outcomes of heroin users found that heroin use predicted a 3-fold to 4-fold excess 

risk of premature death, even when substance abuse was not sustained.45 In 2013, it is 

estimated that OUDs cost the United States more than $78 billion in health care, criminal 

justice, and lost productivity costs.46,47 Early and effective treatment is important. 

Evidence-based treatment options for both prescription opioid and heroin use disorders include 

MAT with methadone, buprenorphine, or naltrexone, as well as behavioral therapies including 

cognitive behavioral therapy. Results for 18-month treatment outcomes from the Prescription 

Opioid Addiction Treatment Study found that, across ten study sites, nearly half of all study 

participants received MAT. Of those initiating treatment, 40 percent received buprenorphine, 

whereas only 6 percent received methadone treatment. Of prescription opioid users seeking 

treatment, 34 percent were engaged in psychosocial services and 40.9 percent reported 

participation in self-help groups.48

Individuals with OUDs are not homogeneous. Different treatment approaches may be 

required, depending on the substance used and other individual characteristics. For example, 

one study found that individuals with a history of misusing prescription opioids were more 

likely to complete a substance use treatment program than were heroin users or individuals 

who engaged in combined opioid analgesic and heroin use.49 Studies also suggest that 

individuals using prescription opioid analgesics may have better treatment outcomes with 

buprenorphine than individuals using heroin who receive similar treatment.49,50 Issues such as 

these indicate a need for individualized, patient-centered treatment.

 

a

Percentages add to more than 100 percent because individuals may receive treatment in multiple 

settings.
9

Factors Influencing Participation in Treatment

Because so many individuals with SUDs do not obtain access to treatment, some exploration of 

factors that influence initiation and engagement in treatment is necessary.

Research shows that many factors may contribute to patients’ initiation and engagement in 

treatment, including: (1) individual; (2) provider; (3) health plan; and (4) market and 

environmental factors. Figure 1 conceptualizes how multiple factors identified in the literature 

can affect this process.

FIGURE 1. Theoretical Model to Explain Participation in SUD Treatment

We examine in greater detail below factors affecting treatment participation that have been 

identified or studied in the past 5 years.

1. Individual Factors

Research has shown that individual patient characteristics--including individual beliefs, 

sociodemographic characteristics, types of substance use and substance delivery modality, 

treatment experience, co-occurring mental illness, cognitive functioning, and patient activation

--may influence treatment initiation and engagement.
10

Individual beliefs. Individual factors, including beliefs, play a large role in an individual’s 

decision about whether to seek treatment. The Surgeon General’s Report on Alcohol, Drugs 

and Health stated that “stigma has created an added burden of shame that has made people 

with SUDs less likely to come forward and seek help” (p. v).12 Research shows that the vast 

majority of people do not seek treatment because of attitudinal or belief barriers (e.g., lack of 

perceived need, concerns about stigma, doubts about efficacy).51 For example, the 2015 

NSDUH found that, of the group identified as needing specialty treatment, only 4.6 percent 

personally felt a need for treatment, and only 1.6 percent of the group needing treatment 

actually attempted to enter into services. Nearly 95.4 percent of all individuals identified as 

having a need for SUD treatment did not feel that treatment was necessary.2

Sociodemographic characteristics. Individual patient characteristics and sociodemographic 

factors such as sex, age, race/ethnicity, education, and insurance may influence decisions to 

initiate and engage in SUD treatment services. This topic has been studied extensively, and we 

briefly summarize the resulting findings below.

 Women may be less likely than men to engage in SUD treatment.7,8,9,10

 Studies are mixed regarding the effects of age on initiation and engagement, with some 

studies showing older age to be beneficial,7,52,53 others younger age,9and some no 

effect of age.54

 Studies examining racial or ethnic differences associated with treatment initiation and 

engagement also produce varied results, including poorer initiation among Black and 

Hispanic populations compared with White populations, and higher rates of initiation 

for Native American and White patients than for other racial and ethnic groups.7,54 

Similarly, several studies show that, compared with the non-Hispanic White population, 

Black and Hispanic populations may have lower rates of treatment engagment.7,42,55,56 

Findings related to treatment continuation also identify somewhat similar results, 

depending on the substance used.55

 Education level also influences treatment initiation and engagement for all racial and

ethnic groups, with lower levels of formal educational attainment associated with 

failure to initiate and engage in treatment.54,55

 Having health insurance also is a predictor of engagement in substance use treatment. 

For example, individuals who were insured had 1.4 times the odds of receiving alcohol 

dependence treatment compared with their uninsured peers.9

CO-OCCURRENCE

A total of 8.1 million Americans aged 18 or older have both a past-year SUD 

and a mental disorder.
11

Substance use and treatment experience. The type of substance use, the route of ingestion, 

and history of SUD treatment also may influence treatment initiation and engagement. 

 Although the evidence is mixed and other factors may influence the results:

o Compared with individuals abusing heroin, individuals who abuse prescription 

opioids are more likely to engage in treatment.57

o Individuals engaged in alcohol abuse may be more likely to engage in treatment 

compared with those who have heroin dependence.55

o Individuals with alcohol or cocaine use disorders may delay treatment longer than 

individuals with other types of SUDs.54

 Substance users who injected opioids were less likely to complete treatment than those 

who did not inject,49 and individuals who never used opioids via a non-recommended 

route (e.g., injection or snorting) were more likely to continue in treatment and abstain 

from illicit opioid use in the final 3 weeks of a 12-week buprenorphine treatment 

program.52

 A prior history of SUD treatment may be associated with delays in the initiation of 

treatment for current needs.52,54

Co-occurring mental illness and SUD. Co-occurring mental health issues are not uncommon in 

the population of those with SUDs, with 8.1 million Americans aged 18 or older having both a 

past-year SUD and a mental disorder. This represents more than 40 percent of adults with an 

SUD and has repercussions for treatment, including initiation and engagement.2 Studies 

examining the co-occurrence of psychiatric conditions and SUDs suggest that dual diagnosis 

may complicate treatment initiation and engagement.11,52

Treatment initiation in those with co-occurring mental illness may be complicated by several 

factors. A study by Brown and colleagues examined treatment initiation in a sample of adults 

with serious mental illness diagnoses including schizophrenia, schizoaffective disorder, major 

depression, and bipolar disorder.11 Researchers defined treatment initiation as completing a 

pretreatment intake assessment, which required two in-person visits over the course of 2 

weeks. The study results indicated that, unlike the general population, males with serious 

mental illness were 54 percent less likely than their female peers to initiate treatment. Brown 

et al.11 also found that the specific serious mental illness diagnosis may influence initiation of 

treatment. Compared with participants with other serious mental illness diagnoses, study 

participants with schizophrenia spectrum diagnoses were less likely to initiate treatment (odds 

ratio = 0.44). Recent drug use also may be a factor in whether individuals with serious mental 

illness initiate treatment.11

Predictors of engagement may differ from predictors of initiation for individuals with serious 

mental illness. Brown et al.11 found that, although patient characteristics and mental illness 

diagnoses may influence initiation, these variables did not predict engagement in SUD 

treatment (defined as attending three or more treatment sessions). Rather, engagement was 
12

predicted by the presence of current drug dependence (compared with recent history of drug 

dependence), patients’ positive feelings toward family members, and having a recent arrest. 

Dreifuss et al.52 found that the co-occurrence of an SUD and major depression was associated 

with improved treatment engagement and outcomes for individuals receiving 

buprenorphine/naloxone treatment for prescription opioid dependence. An example of the 

interaction of individual factors is suggested by the fact that the presence of both a mental 

disorder and SUD may be more prevalent in women--a group that has lower overall rates of 

engagement in SUD treatment.58

Co-occurring SUD and reduced cognitive functioning. Cognitive function may be another 

significant predictor of patient engagement. One study compared rates of therapy session 

attendance for patients with an SUD with or without cognitive impairment. Those with 

cognitive impairment were significantly less likely to attend all of their group therapy sessions 

compared with their peers without cognitive impairment.59

Patient activation. Although not specific to alcohol and SUDs, recent research has found that 

increased levels of patient activation are associated with greater likelihood of treatment 

initiation and engagement for a range of chronic health conditions.60,61,62 Greene and Hibbard 

defined patient activation as “having the knowledge, skills, and confidence to manage one’s 

own health.”61,62 In examining factors related to patient and family activation and accountable 

care organization (ACO) support for and investment in facilitation of such activation, Shortell et 

al. (p. 580)63 found “high-level leadership commitment, goal-setting supported by adequate 

resources, extensive provider training, use of interdisciplinary care teams, and frequent 

monitoring and reporting on progress” to be associated with greater patient activation.

2. Provider Factors

Provider attitudes, access and availability, ease of use, referral source, and the type and efficacy 

of treatment provided affect an individual’s initiation and engagement into SUD treatment. 

Research published in the past 5 years confirms and elaborates on these five overarching 

themes.

Provider attitudes. Just as stigma can negatively affect individuals’ propensity to seek 

treatment, provider attitudes toward those with SUDs may interfere with willingness to work 

with that population.16

Provider access and availability. Lack of provider availability is routinely cited as a barrier to 

patients engaging in treatment.17,18,19 Provider-related financial concerns, such as issues 

related to third-party reimbursement18 and including benefit limits imposed by payers,64 may 

reduce the number of providers willing to offer SUD treatment or restrict their ability to offer 

the full range of treatments that would otherwise be available. As the Mental Health Parity and 

Addiction Equity Act (MHPAEA) of 2008 is implemented, some of these impediments may be 

less pronounced as payers increasingly reimburse the provision of behavioral health care at 

parity with physical health care.
13

PROVIDER ACCESS

Lack of provider availability is routinely cited as a barrier to patients engaging 

in treatment, and provider-related financial concerns may reduce the number 

of providers willing to offer SUD treatment.

The number of providers available to offer treatment, including the number certified to provide 

MAT for OUDs, is one major factor that also influences access. Another is the number of 

certified providers who prescribe buprenorphine--one major MAT option for patients with 

opioid dependence. There has been a continued increase in the number of providers certified 

to prescribe buprenorphine in recent years, which subsequently has increased patients’ access 

to treatment.18 A national survey of physicians certified to prescribe buprenorphine18 revealed 

that this treatment option is largely prescribed outside of specialty treatment settings, further 

expanding access to patients. In 2004, 76 percent of buprenorphine-certified physicians were 

actively providing buprenorphine treatment to opioid-dependent patients. In 2008, the rate 

grew to 86 percent. A related factor is the number of patients each buprenorphine prescriber 

may treat, which also affects the availability of treatment. In 2006, certified prescribers treated 

an average of 18.4 patients with buprenorphine/naloxone. In 2007, a new policy increased the 

number of patients that providers are eligible to treat, and the average number of patients 

treated per physician rose to 27.3 that year and to 39 patients per provider in 2008. A 2016 

amendment to the federal regulation governing the number of patients and types of providers 

who may prescribe buprenorphine is expected to alleviate some of the impediments to 

provider availability and increase the average number of patients per prescriber as well as the 

number and type of certified prescribers.65

Ease of use. Ease of treatment use is important for initiation and engagement. One major 

barrier is length of time until an appointment or opening is available to a prospective patient. 

Longer lengths of time between an index appointment and a treatment initiation appointment 

have been associated with patients’ failure to engage in treatment.7,66 Other research shows 

that decreased wait time is associated with improved retention.67 Treatment in smaller 

facilities also may contribute to patients’ continued engagement, possibly because of the more 

intimate and less stigmatizing nature of smaller settings.7

EVIDENCE-BASED TREATMENTS

Use of several evidence-based practices may be associated with increased 

engagement in SUD treatment, as suggested in recent research.

Referral source. Referral source may be an important predictor of patients’ initiation of SUD 

treatment. Research indicates that this may be influenced partially by system characteristics 

and partially by individual characteristics. Results from recent analysis of treatment episode 

data indicate that, in 2012, only 22.8 percent and 25.8 percent of all outpatient and intensive 

outpatient (IOP) admissions were self-referred, a larger percentage originated from the criminal 

justice system (49.4 percent and 43.9 percent), and the remainder were referrals from other 
14

sources. Short-term and long-term residential treatment also was largely non-self-referred: 

short-term (33.2 percent) and long-term (26.6 percent). In contrast, detoxification was most 

frequently self-referred: free standing residential (55.8 percent), hospital inpatient (74.2 

percent), and ambulatory (50.0 percent).68 Given that detoxification and inpatient settings 

often are accessed in crisis, the referral source may be identified as the patient (rather than a 

source such as a health care provider) whereas residential, outpatient, and IOP settings are 

most easily and commonly accessed by referral. This suggests that lower rates of self-referral 

for outpatient treatment may be the best indicator of patient motivation, whereas referral 

sources for other forms of treatment may be more indicative of how the treatment system 

functions. 

Other research finds connections between referral source and treatment that reveal links to 

both patient characteristics and system functioning. By analyzing admission delays to 

outpatient methadone treatment, Gryczynski et al.54 found that individuals who were referred 

to treatment by a health care provider had lower odds of delayed treatment. In contrast, 

individuals who were self-referred or referred by the criminal justice system were more likely to 

experience a delay in initiating treatment. These findings suggest that system design and 

provider characteristics may be the predominant factor rather than patient motivation. In 

contrast, race or ethnicity also may play a role in conjunction with referral source. Acevedo et 

al.7found an interaction between referral source and the patient’s race in relation to patient 

initiation in outpatient treatment. Among those receiving referrals from the criminal justice 

system, Native American individuals were more likely than White individuals to initiate 

treatment. Native American and Black patients also were more likely to initiate treatment than 

White patients when receiving a referral from a health care provider.

Use of evidence-based treatments. Several evidence-based practices exist for the treatment of 

SUDs, with MAT, contingency management, motivational interviewing, cognitive behavioral 

therapy, and structured individual or family therapies serving as the most prominent 

treatments.69 Use of these practices may be associated with increased engagement in SUD 

treatment. Recent research shows the following:

 Use of methadone or buprenorphine for treatment of OUDs positively influences 

treatment retention.70,71

 Contingency management, a psychosocial therapy offering positive reinforcement such 

as a voucher or prize for abstinence or treatment participation,72 is efficacious for 

maintaining abstinence from alcohol, cocaine, and opioids; for improving SUD treatment 

attendance; and for enhancing group cohesion and therapeutic alliance in early stages 

of group therapy.73,74

 Contingency management combined with other psychosocial therapy interventions such 

as motivational interviewing72 or integrated MAT and mental health treatment75 also is 

effective. Higher rates of service utilization have been seen for co-located mental 

health and methadone maintenance programs when contingency management in the 
15

form of a monetary reward also is provided.75 One drawback of contingency 

management is the potential for unsustainable treatment incentives because of funding 

restrictions.

 Motivational interviewing, which may be used to identify patients’ personal barriers and 

readiness for behavior change relative to substance use,72 is another evidence-based 

practice that may support initiation and engagement. Motivational interviewing is used 

in many health care settings, including SUD treatment,76,77 and it presents an alternative 

to directly inquiring about patients’ inclination for behavior change. Instead, the 

intervention uses a four-step process that builds patient trust until the provider can 

facilitate a patient-developed commitment and action plan for change.76 This has been 

shown to help patients with alcohol use disorder reduce their drinking.78 Motivational 

interviewing and treatment readiness group sessions, combined with monetary 

incentives for enrolling in substance use treatment and attending sessions, was 

associated with higher rates of enrollment in methadone maintenance treatment, reengagement in treatment following a program discharge, and reporting a greater 

number of total treatment days and fewer episodes of heroin use.79

 Receiving group therapy during the initial SUD treatment visit is another predictor of 

continued engagement.7

3. Health Plan/Payer Factors

Health plan factors influence initiation and engagement in substance use treatment. For 

example, health plan policies related to reimbursement, benefit coverage, and types of 

credentialed providers included in a network all affect the development of an adequate 

network for plan beneficiaries and overall access to a care continuum. In addition, favorable 

cost-sharing or alternative payment arrangements such as pay for performance (P4P) and ACOlike models, as well as care management and quality improvement programs, may improve 

treatment initiation and engagement.

Benefit Design. Health plans historically have imposed coverage restrictions, including 

treatment limitations and financial requirements that limit the use of SUD treatment services. 

Limited health plan benefit arrays, including coverage of services or MAT medications, and caps 

on office visits may hinder substance use delivery care, ultimately impeding initiation and 

engagement.21,22 Although many of these barriers are changing with implementation of the 

MHPAEA, health plan policies can substantially affect provider access and ultimately patient 

engagement.

A national survey of private health plans examined how the plans managed specialty behavioral 

health treatment entry and continuing care in 2010. Prior authorization only was required for 

entry into outpatient SUD treatment by 4.7 percent of plans, whereas 73.4 percent required 

prior authorization for continuation of such treatment. Requirements for entry and 

continuation were more strenuous to obtain partial hospitalization, IOP services, or day 
16

treatment, with 94.9 percent requiring prior authorization for entry and 94.5 percent requiring 

authorization for continued treatment. Residential treatment was the most difficult to access, 

with 97.2 percent requiring authorization prior to entry and 95.2 percent for ongoing 

treatment. Prior authorization was based on medical necessity criteria, which were developed 

most frequently by either the plan or by the American Society of Addiction Medicine (ASAM). 

Most plans had formal standards to monitor wait times for routine and urgent care, but 30 

percent lacked such standards for detoxification services.23 Given the implementation of parity, 

it is expected that many of these impediments may have been alleviated.

A study by Grogan et al. (2016) examined state Medicaid plan coverage of the four ASAM levels 

of care: (1) outpatient services; (2) IOP services; (3) residential inpatient services; and (4) 

intensive inpatient services. Researchers used results of a survey and environmental scan 

conducted in 2013 and 2014 to determine that only 13 states and the District of Columbia 

covered all services included in the four levels of care, whereas 26 states and the District of 

Columbia provided coverage for at least one service in each of the four levels. The most 

common restriction in other states was residential treatment, with 21 states providing no 

residential treatment. Ten states did not cover IOP services. Only half of the states and the 

District of Columbia provided funding for recovery support services.24

COVERAGE RESTRICTIONS

Health plan coverage restrictions, including treatment limitations and 

financial requirements that limit the use of SUD treatment services may 

hinder substance use delivery care, ultimately impeding initiation and 

engagement.

A 2014 HHS Substance Abuse and Mental Health Services Administration (SAMHSA) report on 

Medicaid financing of MAT found considerable differences between the states in the state 

Medicaid reimbursement and benefit limits for MAT. Common benefit design elements that 

influence access to MAT for both alcohol and OUDs include use of preferred drug status for 

selected drugs; requirements for prior authorization, step therapy, or psychosocial treatment; 

and quantity or lifetime limits.25

Payment models. Several studies have focused on the use of performance-based payment for 

SUD counselors. Among therapists treating adolescents for SUDs in a community-based 

treatment organization, the providers receiving US $50 for each month that they demonstrated 

competence in substance abuse treatment delivery and US $200 for each patient who received 

a specified number of treatment procedures and sessions were more likely than the control 

group to achieve the target rates of treatment procedures. Additionally, the adolescents in the 

study were more likely to initiate treatment, although there was no significant difference in 

patient remission status.66,80 Where counselors at a community drug treatment clinic could 

earn cash bonuses based on therapy attendance rates of individual clients as well as on the 

quarterly retention rates of their caseload, average therapy sessions attended during the first 

month of treatment increased from 4.6 sessions prior to the intervention to 5.5 sessions per 
17

client during the intervention. The 90-day client retention rate increased from 40 percent to 53 

percent.81

Some state substance use agencies have employed contracts with specialty substance use 

provider organizations that tie payment to performance across various metrics. One wellstudied example is Delaware, which, in 2002, replaced traditional cost-reimbursement 

contracts with performance-based contracting. The state tracked capacity utilization and active 

patient participation in treatment to increase the number of people enrolling in and utilizing 

detoxification services in the state. From 2001 to 2006, the average occupancy rate increased 

at substance abuse facilities from 54 percent to 95 percent. Some of the more successful 

strategies to increase occupancy rates were extending hours of operation, enhancing the 

facility, providing salary incentives to clinicians and utilizing evidence-based therapies.82 

Subsequent studies found that rates of transition to continuing care treatment improved 

following implementation of performance-based contracting,81 and that waiting time declined 

by 13 days whereas treatment length of stay increased.83

PAYMENT TIED TO PERFORMANCE: DELAWARE EXAMPLE

In 2002, Delaware replaced traditional cost-reimbursement contracts with 

performance-based contracting, and saw an average occupancy rate at 

substance abuse facilities increase from 54% to 95% from 2001 to 2006.

Studies also have examined the effect of using an ACO-like payment structure on SUD 

treatment. A qualitative study on the early effects of Medicare ACOs on behavioral health 

processes found that Medicare ACOs were minimally focused on improving processes to 

connect beneficiaries to SUD services; reasons cited included a perceived lack of referral 

resources and a lack of provider training within the organization.84 Researchers also examined 

the effect of the Blue Cross Blue Shield of Massachusetts Alternative Quality Contract (BCBSMA 

AQC) on SUD performance measures of identification, initiation, and engagement. The 

BCBSMA AQC incentivizes provider organizations to control the total cost of care while 

improving quality measures, but they did not include any measures related to SUD in their 

quality measure set to which incentives attached. The researchers found that the BCBSMA AQC 

payment structure had no impact on SUD performance measures.85

A study that did not directly focus on substance use treatment identified some impediments to 

successful use of P4P, at least in certain contexts. A P4P compensation model that strongly 

incentivized primary care physician (PCP) quality outcomes resulted in PCP frustration at 

patient behavior, rather than stimulating greater support for patient self-management and 

activation. However, younger providers and those who were already more patient-centric were 

least likely to express this frustration.86 This suggests that organizational strategies to support 

patient and family activation may be important to supplement the use of P4P,63 as well as 

strategies to support and educate providers.
18

4. Market, Contextual, and Environmental Factors 

Market, contextual, and environmental factors either may contribute to or detract from access 

to SUD treatment. Examples of such factors that influence SUD treatment initiation and 

engagement may include geography, national policies, and state policies.

Geography and regional variation. Research has shown considerable geographic variation in 

treatment availability for SUD treatment generally, often locating treatment gaps in the South, 

Southwest, or Midwest. Results show gaps in availability of providers who accept Medicaid or 

who are licensed to provide buprenorphine for OUD,87 as well as limited public treatment 

services in areas with a high density of African-Americans.88 A recent study examined 

geographic variation in OUD treatment need and admissions to opioid treatment programs 

(OTPs) accepting Medicaid. Of 1,151 of OTPs included in the study, only 65 percent accepted 

Medicaid. Most counties had no access to OUD treatment in OTPs for Medicaid enrollees, with 

the greatest gaps in coverage found in the Great Plains and parts of the Southeast. The highest 

rates of OUD, however, were found in counties in New England, Appalachia and some adjacent 

areas, and Western states. The analysis found clusters of counties with higher-than-average 

rates of OUD and lower-than-average treatment admissions to OTPs accepting Medicaid in the 

Southeast portion of the United States.87 Fifty-three percent of counties in the United States 

do not have a physician with the waiver needed to prescribe buprenorphine.89

National and state policies. National policies can either restrict or improve individuals’ access 

to health care services, especially regarding patients who are publicly insured. As the largest 

funder of SUD services,90,91 Medicaid plays an important role in facilitating access to specific 

treatment modalities. Medicaid policies that promote the use of MAT are critical to patients 

with OUD for their ability to engage in treatment.92 Such policies include providing coverage 

for all forms of MAT, including naltrexone, buprenorphine, and methadone for OUD 

treatment.92 An analysis of evolving state Medicaid policies between 2004 and 2013 found that 

many states implemented changes, including adding buprenorphine to preferred drug lists or 

adding MAT as a covered benefit, thereby promoting access to patient engagement in SUD 

treatment.92

National waiver programs also can be instrumental in increasing access to SUD treatment 

providers. In 2002, the HHS Food and Drug Administration approved buprenorphine for 

prescription by providers who received a waiver from the Drug Enforcement Administration 

(DEA). Providers obtain this waiver after completing educational requirements specific to 

buprenorphine prescribing practices. Prior to the waiver, approximately 98.9 percent of United 

States counties were experiencing a shortage of opioid treatment providers.19 By 2011, 9 years 

after the waiver program went into effect, the percentage of counties experiencing shortages 

decreased to 46.8 percent. In 2011, only 10.4 percent of the United States population resided 

in counties that were classified as having an opioid treatment shortage.19 The 2016 statutory 

and regulatory changes regarding types of providers that may become waivered and the 

number of patients they can serve is anticipated to further improve access to treatment.
19

Single policy changes alone, however, may be insufficient to improve patient initiation and 

engagement in treatment. In 2007, Massachusetts implemented a statewide universal 

insurance law, incorporating SUD services as essential health benefits available to all state 

residents. An assessment of the law’s effect on service uptake revealed that the rate of 

treatment initiation generally was similar to the rate observed prior to the law, and the need 

for SUD treatment remained relatively high.93 Qualitative interviews with community-based 

SUD treatment organizations revealed that, although coverage had been expanded, patients 

experienced barriers to processing their insurance applications. Because the state no longer 

allowed citizens to benefit from acute or emergency service coverage under Medicaid’s 

presumptive eligibility status, patients often could not access timely care for their SUD needs. 

Additionally, co-payments continued to represent a significant barrier to patients’ treatment 

initiation and continued use of services.93

In 2010, the Patient Protection and Affordable Care Act (Affordable Care Act) expanded both

public and private insurance coverage, providing greater access to health care. With regard to

SUD treatment, the Affordable Care Act eliminated lifetime caps on treatment services and 

restricted the annual caps that insurance plans can impose.94 Reducing these insurance-related 

barriers to treatment may affect the number of individuals initiating and continuing to engage 

in SUD services, although lack of treatment resources in certain areas, as well as non-expansion 

of Medicaid in certain states, may continue to impede access to those services.95

AFFORDABLE CARE ACT

The 2010 Affordable Care Act eliminated lifetime caps on SUD treatment 

services and restricted the annual caps that insurance plans can impose.

Reducing these insurance-related barriers may affect the number of 

individuals initiating and continuing to engage in SUD services. 

Additionally, the Affordable Care Act allows young adults aged 19-25 years to remain under 

their parents’ insurance coverage. Initial assessments of the effect of the legislation on young 

adults’ use of substance use services failed to reveal any significant change in treatment 

uptake.96 However, given the relatively high rates of substance abuse for this age group,1

expanded coverage ultimately may promote increased uptake of treatment services. 

A study examining the direct effect of the MHPAEA on SUD treatment outcomes found that, 

after the first year of implementation, no significant change was observed in patient initiation 

or engagement.97 However, the direct effects of this law on patient outcomes may be delayed 

as health plans adjust to and incorporate their new coverage requirements. Health plans also 

are still in the process of satisfying more recent regulatory requirements,98 which also will 

influence implementation.
20

Initiation and Engagement in Treatment 

A basic requirement of successful SUD treatment is that the individual enter treatment and 

continue to participate long enough to benefit from what the treatment can offer. These steps 

of entry into treatment and treatment retention are commonly labeled as initiation and 

engagement. Without initiation and engagement, meaningful treatment does not occur. 

Treatment initiation and engagement have been defined in different ways. Treatment initiation

generally indicates that a patient has attended at least one treatment or assessment session 

after being identified as someone who needs treatment for alcohol or drug use disorder or 

following an admissions process.7,11 Treatment engagement implies continued treatment 

through additional visits, usually a specified number of encounters occurring within a set time 

period, which may vary depending on the study definition. Engagement also may be examined 

under the rubric of retention or completion. Presently, the most commonly used definitions are 

derived from the IET performance measure, which sets a minimum floor for initiation and 

engagement. We discuss the IET measure definitions in detail in the Methods section of this 

report, but the simple definitions are as follows:

 Initiation: the percentage of members who initiate treatment through an inpatient 

alcohol and other drug (AOD) admission, outpatient visit, IOP encounter, or partial 

hospitalization within 14 days of diagnosis.99

 Engagement: the percentage of members with a diagnosis of AOD dependence who 

initiated treatment and had two or more additional services within 30 days of the 

initiation visit.99

Initiation and Engagement Measures 

TREATMENT INITIATION

Indicates that a patient has attended at least one treatment or assessment 

session after being identified as someone who needs treatment for alcohol or 

drug use disorder or following an admissions process.

According to the National Quality Forum, performance measures “serve as a critically important 

foundation for initiatives to enhance healthcare value, make patient care safer, and achieve 

better outcomes.”100 At this point, there are hundreds of performance measures, but the most 

prominent measure related to SUD treatment is the IET measure.

TREATMENT ENGAGEMENT

Implies continued treatment through additional visits, usually a specified 

number of encounters occurring within a set time period.
21

The Healthcare Effectiveness Data and Information Set Measure of Initiation and Engagement

1. IET Measure Development and Adoption

The IET measure was developed by the Washington Circle group in partnership with SAMHSA 

and the National Committee for Quality Assurance (NCQA) and was designed to be calculated 

using administrative claims data.101,102 In 2004, NCQA included the IET measure in their 

Healthcare Effectiveness Data and Information Set (HEDIS) quality measures.101,102 The HEDIS is 

the most commonly used set of quality measures in the United States managed health care 

industry; over 75 percent of United States health plans use them to measure performance.103 

The IET measure is part of both the HEDIS Health Plan measures and the HEDIS Physician Plan 

measures.104 In addition to use in the HEDIS measures, HHS uses the IET measure in many 

quality reporting programs, including the following:

 HHS Centers for Medicare & Medicaid Services (CMS) Adult Core Set of Health Care 

Quality Measures for Medicaid (Adult Core Set).

 Medicare and Medicaid Meaningful Use (MU) Electronic Health Records (EHR) for 

Eligible Professionals and the MU Stage 2 clinical quality measures, which now are part 

of the Merit-based Incentive Payment System (MIPS).

 CMS Medicare Physician Quality Reporting System, which is now part of the MIPS.

 Physician Feedback/Quality and Resource Use Reports.

 Physician Value-Based Payment Modifier.

 Health Insurance Marketplace Quality Initiatives Quality Rating System and Qualified 

Health Plan Enrollee Experience Survey.

 CMS Medicare Part C/Medicare Advantage (Part C Star Rating and/or Medicare Part C 

Display).

 CMS Medicare and Medicaid Financial Alignment Demonstrations.

 CMS Medicaid Health Homes.

 CMS Medicaid Innovative Accelerator Program.

 CMS Medicaid 1115 Waver on Institutions for Mental Disease (IMD).

 SAMHSA and CMS Behavioral Health Clinic (BHC) Quality Measures in use as part of the 

Section 223 Demonstration Program for Certified Community BHCs.104,105,106,107,108
22

In addition, the IET measure is used by at least four state Medicaid programs to tie Medicaid 

reimbursements to health plan performance within state Medicaid ACOs. Those states are 

Maine, New Jersey, Vermont, and Oregon.109,110,111 The IET measure was endorsed by the 

National Quality Forum in 2009 as measure number 0004.104

2. IET Measure Validity 

Measure validity is critical if one is to draw conclusions from measure rates. Harris and 

colleagues have performed a series of studies to assess the validity of the IET measure, 

including assessing whether the codes used in calculation correspond to the receipt of 

substance use treatment.112,113 Harris et al.114 and Garnick, Dunigan, and their colleagues also 

have examined the relationship of the measure to outcomes.115,116,117

Studies of the relationship of IET codes to receipt of treatment originated in and used data from 

the Veterans Health Administration (VHA) National Patient Care Database. They assessed 

whether there was agreement between the code combinations and clinical progress notes 

regarding treatment. The first such study concluded that VHA SUD specialty facilities had high 

concordance with clinical progress notes (92 percent to 98 percent accuracy), whereas outside 

outpatient clinics had a concordance rate of 63 percent and non-SUD specialty inpatient units 

had a concordance rate of only 46 percent. The researchers concluded that, outside of SUD 

specialty clinics that were integrated into the VHA, patients may be counted as meeting the 

HEDIS measures even though they may not have received addiction treatment.112 A follow-up 

study found the results in VHA SUD specialty clinics virtually unchanged (90 percent to 96 

percent) accuracy. However, non-SUD outpatient and non-SUD inpatient clinics improved to 77 

percent and 65 percent concordance with documentation of clinical progress notes, 

respectively.113

Studies also show that IET rates correspond with some patient outcomes but not others. Harris 

and colleagues114 found that individuals meeting the HEDIS engagement criterion had 

statistically significant improvements on the Addition Severity Index alcohol, drug, and legal 

composite scores, although the improvements were not clinically significant. Garnick and 

colleagues116 found that engagement in publicly funded outpatient treatment services was 

associated with decreased risk of subsequent arrests. Dunigan and colleagues117 examined the 

relationship between treatment engagement on employment using multiple outcomes of 

employment (i.e., any employment, wages, number of quarters employed, and hours worked).

Although they did not find a relationship between engagement and employment in the overall 

sample, they did find a relationship between engagement and employment and higher wages 

for those individuals with a history of criminal justice involvement. Similarly, Garnick et al.115

found improved performance on multiple substance use outcomes among adolescents who 

engaged in treatment.
23

NCQA QUALITY COMPASS DATA

Analysis of these data indicates that rates of initiation are higher than rates of 

engagement across all commercial, Medicaid, and Medicare plans.

3. Structure of the Measure, Including Non-inclusion of MAT

The process for calculating the IET measure rates is explained in detail in the Methods section 

of this report, as the initiation and engagement rates are dependent variables in quantitative 

analyses undertaken as part of this study. Performance measures, however, are updated often, 

most typically with minor revisions to codes used for calculation. Changes to the HEDIS version 

of the IET measure for 2018 included more substantive changes, such as one addressing the 

former non-inclusion of MAT in the calculation of receipt of substance use treatment as part of 

the measure numerator.118 MAT is now a major part of SUD treatment for alcohol and OUDs, 

and the amendment addresses that fact, recognizing that initiation or engagement in treatment 

may include receipt of MAT. Other key changes for 2018 include the addition of services 

received by telehealth, stratification by age and diagnosis, and extension of the time measured 

to satisfy the engagement measure from 30 to 34 days. Many of these changes reflect the 

evolving nature of SUD treatment.

Health Plan Trends for the IET Measure

Since inclusion of IET in the HEDIS measures in 2004, considerable data have been generated 

that provide information on rates of initiation and engagement. Analysis of NCQA Quality 

Compass data indicates that rates of initiation are higher than rates of engagement across all 

commercial, Medicaid, and Medicare plans. Medicare initiation rates generally have been 

higher than either commercial or Medicaid rates and, for Medicare, Medicaid, and commercial 

insurance, rates for both measures tend to be lower for health maintenance organization 

(HMO) plans compared with preferred provider organization (PPO) plans.

Commercial HMO and PPO plans. Figure 2 displays the initiation and engagement trends for 

commercial HMO and PPO plans from 2005 through 2014. Initiation rates are slightly higher for 

commercial PPO plans than for commercial HMO plans. However, rates for both have steadily 

decreased over the last decade. In 2005, 45.8 percent of commercial PPO plan members and 

44.5 percent of commercial HMO plan members needing alcohol or drug services initiated 

treatment. In 2014, the percentages of commercial PPO and HMO plan members initiating 

treatment dropped nearly 10 percent for both categories to 36.1 percent and 34.7 percent, 

respectively. Rates of engagement, although much lower than rates of initiation, have 

remained stable across commercial PPO and HMO plans over the last decade. The mean rate of 

engagement for PPO plans is 15.4 percent, and the mean rate for HMO plans is 14.6 percent.
24

FIGURE 2. IET for Commercial HMO and PPO Plans, 2005-2014

SOURCE: Author summary of findings from NCQA Quality Compass data.119

Medicaid HMO plans. Figure 3 demonstrates the rates of initiation and engagement for 

Medicaid HMO plans from 2005 through 2014. Both initiation and engagement rates were 

highest in 2007 at 45.6 percent and 14.4 percent, respectively. Since then, rates for both 

measures have decreased. The last 3 measured years represent the lowest initiation rates 

recorded, as well as 3 consecutive years of lower-than-average engagement rates for Medicaid 

HMO plans.
25

FIGURE 3. IET for Medicaid HMO Plans, 2005-2014

SOURCE: Author summary of findings from NCQA Quality Compass data.119

Medicare HMO and PPO plans. The average initiation rates for Medicare plans are higher than 

rates for plans under either commercial or Medicaid insurance (Figure 4). Across the last 10 

years, Medicare HMO plans have averaged around a 43.4 percent initiation rate, compared 

with 41.6 percent in Medicaid and 41.1 percent in commercial HMO plans. The average 

initiation rate for Medicare PPO plans is even higher (48.6 percent), compared with the 

commercial PPO plan average (42.4 percent). As with Medicaid, Medicare plans experienced 

the highest rate of initiation in 2007, with 50.4 percent in HMO plans and 56.5 percent in PPO 

plans. While HMO plans have seen a steady decrease in initiation rates over time, initiation 

rates for Medicare PPO dropped in 2008 before spiking in 2009 and 2010; however, Medicare 

PPO rates have decreased substantially since 2010. In 2014, only 35.1 percent of those needing 

treatment initiated care in Medicare PPO plans and only 32.5 percent initiated care in Medicare 

HMO plans. Rates of engagement also decreased over time. Between 2006 and 2008, 

Medicare PPO engagement rates were higher than those associated with Medicare HMO plans. 

Since 2009, rates of engagement have remained similar and stable between both plan types. In 

2014, 3.3 percent of those needing treatment engaged in care with a Medicare HMO plan, and 

3.5 percent engaged in services with a Medicare PPO plan.
26

FIGURE 4. IET for Medicare HMO and PPO Plans, 2005-2014

SOURCE: Author summary of findings from NCQA Quality Compass data.119

Interventions Designed to Improve Initiation and Engagement 

Several best practices and intervention components for treating SUDs have been developed to 

address some of the barriers to initiation and engagement. One type of intervention that is 

discussed in the section above is the implementation of evidence-based clinical practices. 

Many of these practices have been shown to enhance treatment retention, and efforts to 

incorporate their implementation in facilities could be expected to increase initiation and 

engagement rates. There is not, however, complete consensus within the addiction specialist 

community as to which practices truly meet “best practice” standards.120

In the section below, we discuss two other categories of interventions identified in the 

literature: (1) interventions that have been studied to address special populations; and (2) 

organizational interventions.

Interventions to Address Special Populations

Recent research has examined factors that are important in targeting SUD interventions for 

young adults, ethnic minorities, and individuals with co-occurring psychiatric illness. Many of 

these interventions focus on increasing the “fit” of the treatment with the targeted 
27

demographic as well as increasing availability and access to treatment through enhanced 

contact or coordination.

Young adults. Young adults may respond to treatment differently than older individuals, and 

age-specific approaches may enhance initiation and engagement. Examples include whether 

they thrive and remain in treatment better when they are with individuals of similar age and 

whether they may be more likely to engage in treatment if a harm reduction model is 

employed.

Results are mixed on whether young adults do better when in treatment with people of similar 

ages. For example, younger adults face age-related challenges in engaging with other 12-step 

members.121 Only 15 percent of Alcoholics Anonymous or Narcotics Anonymous 12-step 

members are younger than 30 years. Additionally, younger adults may find it difficult to 

identify other similarly aged individuals who are engaging in sobriety.121,122 Thus, it may be 

challenging for younger adults seeking treatment to engage with the majority of members in 

these programs.122,123 Labbe et al.123 examined 12-step meeting attendance among adults aged 

18-25 years and found that the age composition of participants in meetings significantly 

moderated the effect of attendance on abstinence. The study results suggested that linking 

younger adults who were prone to non-adherence to meetings attended by similarly aged 

peers may improve treatment during the early phases of recovery. However, the results also 

suggested that continued attendance in meetings with peers of the same age group may be 

detrimental to encouraging long-term engagement. Research also shows that young adults 

prefer to reduce their intensity of substance use rather than to fully abstain from use.124 

Ethnic minorities. Culturally relevant care also plays a major role in patient engagement. A 

qualitative study examining barriers and facilitators to SUD treatment engagement for 

American Indian and Alaska Native populations revealed that many providers employ a diverse 

array of health practices and culture-based interventions to deliver substance abuse treatment 

services.125 SUD program directors and Single State Authority (SSA) representatives explained 

that incorporating traditional interventions created a supportive treatment environment for 

culturally diverse patients. Additionally, providers found that respecting cultural taboos, 

including not documenting healing practices, was useful to engaging Alaska Natives and 

American Indians in SUD treatment. To facilitate this culturally competent care delivery system, 

several providers and Single State Authorities reported conducting educational trainings with 

staff as a way to improve knowledge and use of the cultural interventions.125

Co-occurring substance use and mental disorders. Individuals with co-occurring substance use 

and mental disorders have a high-risk for treatment non-adherence and dropout.26,126 

Specialized interventions may aid in increasing this population’s initiation and continued 

engagement in care. For example, psychosocial interventions delivered through brief in-person 

sessions and follow-up calls with the patient, as well as through another family member, were 

shown to improve treatment adherence for individuals with bipolar disorder and a SUD.126
28

Providers may need to pay special attention to younger adults with co-occurring SUDs and 

mental disorders. As previously stated, younger adults aged 18-25 years are at the highest risk 

for SUDs.1 Recent research also suggests that individuals in this age group with serious mental 

illness are more likely to engage in substance abuse.92

Integrated treatment may be a useful method for treating individuals with co-occurring needs 

and may encourage improved initiation and engagement. Integrated treatment focuses on 

providing health care services and monitoring two or more conditions, such as a mental health 

condition and SUD. Patients with integrated treatment often receive a combination of 

therapies, including psychotherapy and pharmacotherapy. Integrated treatment also may 

involve a team of providers including a PCP, psychotherapist, and social worker or case 

manager to help coordinate the patient’s care.26 In a recent review of empirical studies focused 

on treatment outcomes for individuals with co-occurring conditions,26 the authors found that 

case management is an important component in decreasing clients’ needs for inpatient 

treatment and increasing their time in the community. Kelly and Daley26 found that care 

models for patients with co-occurring conditions that emphasized the use of case managers 

who provided continuous support were associated with: (1) patients staying in the community 

longer; (2) decreased need for inpatient treatment; and (3) decreased drug use and 

psychosocial issues. 

Organizational Interventions

In this section, we describe interventions implemented largely at the organizational level. First, 

we summarize the results of two large efforts at improving SUD treatment access and 

retention. These two initiatives were implemented across multiple states and providers to 

identify solutions to improve access to care and decrease “no-show” rates. Solutions often 

were individualized for each provider, but several overarching themes emerged. Themes from 

the results of these initiatives are summarized in Table 6. Second, we report on studies of 

enhanced outreach by providers and, third, on transformation to patient-centered service 

delivery. Fourth, we report on efforts underway that are not yet the subject of study but that 

reflect systematic approaches that may prove useful to improve SUD treatment access.

Multisite interventions aimed to improve access and engagement. Between 2007 and 2010, 

10 states participated in the Strengthening Treatment Access and Retention--State Initiative 

(STAR-SI) program conducted by SAMHSA.127 Through this initiative, states developed 

innovative interventions to decrease the number of individuals who do not show up for SUD 

treatment in up to 15 of their local outpatient clinics. State-level results then were aggregated 

to determine which interventions were most effective in increasing linkage to care. As 

previously discussed, behavioral engagement strategies and reminder calls were efficacious in 

reducing no-show rates. Additionally, several outpatient clinics conducted organizational-level 

interventions to improve engagement.127

Wait time was identified as a major barrier to appointment adherence. Among the 11 clinics 

reporting this barrier, the overall rate of patients who did not attend treatment that was 
29

attributed to wait time was 41.7 percent. Facilities implemented different organizational 

interventions to reduce their wait times, including offering walk-in appointments, doublebooking appointments, and altering the way visits were scheduled. In one facility, the ability of 

providers to book their own appointments was replaced with a centralized appointment 

scheduling system. After implementing such interventions to reduce wait times, the overall noshow rate of patients that could be attributed to this factor was reduced by more than 20 

percent.127

Delays in the admissions process also were cited as a barrier to patients attending their 

appointments at STAT-SI facilities.127 Treatment attrition during the admissions phase is a welldocumented barrier to engaging patients in care. In a recent literature review, Loveland and 

Driscoll128 found that attrition primarily occurs within the first 24-48 hours following patients’ 

initial request for services and increases in likelihood with each day that a patient waits to begin 

treatment following their initial request. Linking individuals to care on the same day as their 

initial service request was significantly associated with increased appointment adherence. 

Across the five studies they assessed, patients linked to treatment on the same day as their 

request were 2.5 times more likely to attend their treatment appointments, compared with 

individuals who waited 3-7 days for an appointment.128

Within the STAR-SI study, some facilities opted to redesign their admissions process to reduce 

wait times between appointments. Most facilities altered their processes by reducing the 

number of steps required by patients before their first appointment, resulting in an over 20 

percent reduction in no-show rates across all STAR-SI treatment centers.127 Other approaches 

included increasing clinical capacity, which reduced no-show rates by 24.3 percent in six 

clinics.127 Enhancing collaboration with SUD treatment referrers also helped decrease clinics’ 

no-show rates. In some cases, collaboration was enhanced by asking the referrer to offer the 

client an incentive to attend treatment while, for patients referred through the criminal justice 

system, they advertised a penalty for not attending the visit. Finally, simply creating a more 

visually attractive and welcoming treatment environment through décor changes helped 

improve patients’ comfort levels and decrease no-show rates by nearly 6 percent.127

The Network for the Improvement of Addiction Treatment (NIATx) initiative presents another 

national effort to improve SUD treatment initiation and retention in local clinics. The NIATx 

model of process improvement for behavioral health encourages individual treatment facilities 

to first conduct an agency walk-through to better understand how patients interact with 

organizational elements of treatment including reception services, initial screening, 

assessment, admissions, and treatment planning processes.129 A change team then is 

established to further identify barriers to treatment engagement in the current organizational 

processes and to design and implement interventions in a rapid-cycle testing environment. 

Continuous monitoring and evaluation of the interventions are conducted to assess 

improvements and determine where additional resources are needed.129

Los Angeles County treatment facilities were included in a phased pilot study of the NIATx 

model between 2005 and 2008.129 Each of the SUD agencies identified its own improvement 
30

objectives on the basis of agency walk-throughs and a review of baseline patient engagement 

data. Change leaders implemented a variety of interventions to improve admissions processes 

and treatment retention and to reduce no-show rates. Interventions included increasing 

contact with prospective patients prior to admission, conducting same-day assessments to

improve efficiency, and reducing the amount of paperwork completed for intake and 

assessment processes. Treatment facilities aiming to improve appointment adherence 

attached patient incentives to appointments, began providing physical appointment cards to 

patients, and conducted satisfaction surveys to continue engaging patients in treatment. 

Aggregate data suggested an 83 percent reduction in no-show rates related to assessment and 

intake barriers and a 39 percent increase in 30-day retention during phase one of the pilot 

study.129

Phase two of the study included 12 SUD treatment facilities with similar improvement 

objectives. Facilities seeking to decrease the waiting time between patients’ initial contact to 

their intake or assessment appointment developed various interventions.129 For example, they 

merged preassessment phone interviews into a single interview that was conducted during the 

patient’s first interaction with the facility. Other interventions included increasing assessors’ 

appointment availability, offering walk-in assessment services, and sending case managers to 

prospective patients’ homes to complete assessment paperwork. Following the interventions, 

the average wait time between appointments was 3.5 days--approximately 2.5 days shorter 

than the facilities’ target.129

SUD facilities that aimed to achieve overall decreases in their no-show rates for intake and 

assessment appointments relied on a combination of organizational and incentivized changes. 

Interventions included maintaining contact with waitlisted prospective patients through daily 

check-in calls, providing reminder calls the day before assessments, redesigning intake systems 

to include more assessment appointment times, adjusting appointment times to help clinicians 

complete paperwork in a timely manner, and providing bus tokens to incentivize patients to 

attend the appointments.129 Another successful tactic involved assignment of patients by the 

primary counselor to a group schedule at intake and allowing counselors to complete new 

patient assessments at a later appointment. Aggregate data across all facilities with intake or 

assessment appointment goals demonstrated a 43.4 percent decrease in no-show rates.129

FOCI FOR ORGANIZATIONAL INTERVENTIONS

Interventions focus broadly on improving outreach, reducing wait times for 

both initial and subsequent appointments, using incentive programs, 

decreasing the complexity of the initial intake process, and improving the 

patient’s experience.

Substance use treatment facilities seeking to improve 30-day retention in treatment adopted a 

practice of holding weekly meetings with patients during the first 4 weeks of treatment to 

assess patient satisfaction with the program and treatment plan.129 Patients were asked to 

complete surveys regarding ways to further improve treatment. Facilities also adjusted their 

set meal, medication, and mail delivery times to better accommodate patients’ schedules. The 
31

establishment of one-on-one welcome meetings between new patients and staff members 

from different departments within the treatment facility also promoted retention.129

Several themes emerged among these initiatives as foci for organizational interventions (Table 

6). Specifically, interventions were focused broadly on improving outreach, reducing wait times 

for both initial and subsequent appointments, using incentive programs, decreasing the 

complexity of the initial intake process, and improving the patient’s experience.

TABLE 6. Themes for Multisite Improvement Efforts to Enhance Initiation and Engagement

Theme Examples of Organizational Interventions

Enhanced outreach  Making outreach calls with appointment reminders

 Enhancing collaboration with the referral source

 Increasing contact with patients prior to admission or with those

on a waiting list

 Providing physical appointment cards

Reduction of wait times 

for intake 

appointments or 

between appointments

 Increasing clinical capacity by hiring additional providers

 Enhancing collaboration with referral source

 Conducting same-day assessments or providing walk-in 

assessments

 Centralizing appointment scheduling and increasing 

appointment availability

 Having counselors assign group schedule at intake

Appointment 

incentives

 Advertising penalties for not attending appointments

 Providing patient incentives for attending appointments, such as 

bus tokens

Decreasing complexity 

of intake processes

 Reducing paperwork for intake and admissions

 Combining multiple preassessment interviews into 1 interview 

conducted during patient’s initial contact

 Having case managers make home visits to complete paperwork

 Altering the length of appointments to allow providers to 

complete paperwork

 Allowing providers to take more than 1 appointment to 

complete assessment paperwork

Improving patient 

experience

 Improving decor and environment to make it feel more 

welcoming

 Using satisfaction surveys or meetings to assess patient 

satisfaction

SOURCE: Author summary of reports of results of the STAR-SI127 and NIATx129 multisite 

studies.

Enhanced outreach. Additional research examined the use of mobile phone strategies to 

decrease non-attendance rates. Patients who fail to attend appointments are more likely to 

drop out of treatment and experience poor outcomes.73 Meta-reviews of previous research 

suggest that appointment reminders sent through text messages to patients’ mobile phones 

improve treatment attendance, compared with individuals receiving no reminders.130,131,132 
32

Text reminders represent an efficient intervention by health service providers to improve 

treatment initiation and adherence130 and also may be a cost-effective alternative to traditional 

reminders through phone calls.132 Mobile phone-based interventions also can be used to 

support patients’ motivation for behavior change. Spohr et al.133 found that regularly 

reminding patients of their short-term life goals resulted in higher likelihood of SUD treatment 

initiation and appointment adherence. Patients who opted not to receive text message 

reminders attended 56 percent fewer days of treatment. Additionally, phone calls reminding 

patients of next-day appointments have been useful in reducing the number of patients who do 

not arrive for intake and assessment appointments as well as in increasing treatment 

retention.73,129

Patient-centered service delivery. Patient-centered care is a growing movement in health 

services, exemplified by the new emphasis on the creation of medical homes and integrated 

care models. This model, which encourages care coordination as well as shared decisionmaking and patient-centered care, is vastly different from more common models of addiction 

care. Specifically, individuals with alcohol use disorders traditionally have been offered 

standalone, group-based, 12-step programs.134 Although these programs can be efficacious, 

they do not offer wraparound services or additional treatment options such as MAT, which may 

help engage some patients in care.134

One aspect of providing patient-centered care is ensuring a high level of coordination between 

patients’ providers. Patients who receive a greater level of coordinated care across their 

primary and specialty care providers, as demonstrated through jointly developed discharge 

plans and referral to local resources, remain in care longer than patients who do not receive 

such coordinated care.27 Research suggests that the positive association between higher levels 

of continuity-of-care practices exists for both the general population of individuals seeking SUD 

treatment and for a subgroup of that population experiencing co-occurring psychiatric 

disorders.27

VERMONT

Vermont initiated the health home “hub and spoke” model in 2013 for 

individuals with OUDs and mental health conditions. This model uses 

regional opioid treatment providers as hubs to initiate treatment and 

incorporates a team of office-based opioid treatment providers to deliver 

ongoing support.

One model of patient-centered integrated care that is increasingly focused on patients with 

SUDs is Medicaid health homes. Although the results of these initiatives are not yet available, 

three states--Vermont, Rhode Island, and Maryland--have initiated Medicaid health homes for 

individuals with SUDs.135 Medicaid health homes require six core services: comprehensive care 

management, care coordination, health promotion, comprehensive transitional care follow-up, 

individual and family support, and referral to community and social support resources. 
33

Vermont initiated their health home “hub and spoke” model in July 2013 for individuals with 

OUDs and mental health conditions. This model uses regional opioid treatment providers as 

hubs to initiate treatment or provide care to complex patients, and it incorporates an enhanced 

team of office-based opioid treatment providers to deliver ongoing support for less complex 

patients.135 

Rhode Island also initiated Medicaid medical homes focused on individuals who receive or 

qualify to receive MAT135 and have enhanced the services of their opioid treatment providers to 

offer the range of services required by a medical home. Finally, Maryland initiated their health 

homes in October 2013, for beneficiaries with OUDs and a co-occurring mental or physical 

condition and for individuals with serious and persistent mental illness. Their health homes are 

based in opioid treatment centers for individuals with SUDs and in either psychiatric 

rehabilitation programs or mobile treatment providers for individuals with severe and 

persistent mental illness.135 

Shared decision-making is another model of patient-centered care that can be useful for 

individuals with SUDs. When patients engage in shared decision-making with providers, their 

individual preferences, values, and needs are considered in treatment planning. Shared 

decision-making between providers and patients also ensures that patients have a better 

understanding of their medical conditions and are supported throughout the treatment 

process.76,134,136,137,138 When patients are actively involved in health care and self-management 

decisions, they are more likely to engage in care and adhere to treatment.136 Patient-centered 

care models can be used in addiction treatment to improve care coordination across primary 

and specialty care providers and to ensure that patients have access to all necessary resources 

to promote their full engagement and retention in care.139

Promising practices also have been developed in areas that are not specific to SUD treatment. 

Care management models that incorporate such practices as frequent face-to-face contact, 

facilitated exchange of patient information among providers, and patient education and 

behavioral change techniques such as motivational interviewing, have been shown to decrease 

inpatient admissions among high-risk Medicaid enrollees with chronic conditions.140,141

Unstudied systematic approaches. Many systematic interventions are underway that have not 

been the subject of published studies. One such intervention is being promoted by the 

Healthcare Fraud Prevention Partnership (HFPP), which is a group of health plans, state and 

federal agencies, and others working to prevent fraud and waste associated with opioid 

prescribing. Although the focus is fraud and waste, they simultaneously are seeking ways to 

promote recovery from OUD. Priority actions that fall within this goal are: (1) promoting access 

to MAT; and (2) encouraging the use of data that can be used for activities such as identifying 

patients at risk of opioid misuse and OUD and providing intervention. The HFPP recommends 

use of cross-payer data to facilitate these goals. HFPP also seeks to identify and broadly 

disseminate effective methods for treating OUD. Although much of the HFPP effort relates to 

reducing inappropriate prescribing and misuse, the approaches being taken also can be 

instructive for promoting access to treatment. These include provider education regarding 
34

guidelines, continuing medical education credits, and a form of “academic detailing” that uses 

individual consultation. Patient education also plays a role, with HFPP members engaged in 

segmenting audiences to deliver information where it is needed and developing resources that 

fit the audience. A third focus, aimed at getting enrollees into MAT, includes approaches such 

as educating providers, use of technology such as the SAMHSA mobile app, promoting use of

new pharmacological formulations such as implantable buprenorphine, promotion of 

Screening, Brief Intervention, and Referral to Treatment (SBIRT), and use of telehealth. HFPP 

also seeks to promote use of data to identify problems with opioid use and target corrective 

action. Some of the data systems available may be prior authorization systems, claims 

processing systems, and payer data warehouses. The HFPP is attempting to develop methods 

for its members to share such data but recognizes that constraints such as privacy may be a 

barrier. Similar barriers exist that often prevent health plans from accessing Prescription Drug 

Monitoring Program (PDMP) data. Drug utilization reviews, which presently may result in 

pharmacy lock-ins, are other potentially useful sources of information.142

Another systematic approach was announced by the State of Oregon in 2017. The state plans 

to create a single point of shared responsibility for behavioral health needs for local 

communities through a regional governance model. The intention is to have all Oregonians 

served by a coordinated care model for behavioral health--essentially an expansion and 

modification of the Coordinated Care Organization model that has been in place since 2013 for 

Medicaid. The model integrates care across systems, so all organizations in a community that 

are responsible for behavioral health (e.g., community mental health organizations, hospitals, 

law enforcement, schools, physical health care) will be part of a governance structure to ensure 

that local resources are used in the most effective way and that there is coordination of care.143

Three health plans in California have developed their own approaches to dealing with opioid 

misuse. Partnership Health Plan of California, a Medicaid plan, approached prescriber 

education related to overprescribing through incremental formulary changes. These changes 

were accompanied by intensive education, including in-person regional meetings, webinars 

with remote facilitators, promoting local development of prescribing guidelines, academic 

detailing, technical assistance and support related to conversations with patients that 

encouraged use of outside authority as the rationale for unpopular changes, outlier review, and 

pharmacy lock-in. They also provided alternative benefits such as acupuncture and chiropractic 

care, even though these services are not part of the California State Medicaid plan. Blue Shield 

of California, a commercial plan, added formulary controls, provided utilization reports to 

prescribers meeting certain criteria, and offered provider outreach for prescribers with 

problematic prescribing. They also offered prescriber education, provision of alternative 

benefits, use of lock-in programs, opioid safety coalitions, and advocacy efforts related to drug 

disposal. Kaiser Permanente of Southern California launched a safe opioid prescribing initiative 

for all lines of business that had support from the plan’s leadership. It used data to help 

providers see the scope of the overall problem as well as more specific problems, built 

collaboration teams, relied on peer pressure and support for clinicians, and invested in clinician 

education. They also offered formulary management, facilitated use of EHRs to incorporate 

decision support, endorsed and further developed emergency department and urgent care 
35

guidelines, enlisted pharmacists to ensure that they also had responsibility for improving opioid 

access, developed interspecialty support agreements, and provided patient education and 

support.

144
36

STUDY OBJECTIVES AND HYPOTHESES 

The aim of this study is to expand on the literature concerning individual, provider, health plan, 

market, and environmental factors that influence initiation and engagement in SUD treatment 

services. Specifically, the research team examines how these factors affect health plan 

performance on the IET measures for both commercial and Medicaid health plans. 

Acknowledging that the reporting parameters of the IET measures themselves may influence 

how health plans develop quality improvement initiatives targeting health plan benefits or how 

providers and beneficiaries interact with treatment services related to substance use, we aim to 

use stakeholder interviews to provide insight on measurement performance.

Thus, the study has two overarching objectives:

 Determine the models of care, quality improvement interventions, and best practices 

used by higher-performing health plans to improve initiation and subsequent 

engagement in SUD treatment.

 Describe the provider, beneficiary, and market factors that affect their ability to 

successfully initiate and engage beneficiaries in substance use treatment services.

On the basis of existing literature, the research team hypothesized that health plans that 

performed well on the IET measures would be highly integrated behavioral and physical health 

service models; they would reimburse for a variety of substance use treatment-related services 

including case management, routine outreach, peer supports, outpatient, inpatient, partial 

hospitalization, and residential treatment; they would have high network adequacy and provide 

financial incentives for providers; and they might be more likely to serve smaller markets in a 

community-oriented model rather than be plans with large beneficiary enrollment covering 

diverse populations and geographic areas.
37

METHODS 

To determine the factors that contribute to health plan success in engaging plan members in 

SUD treatment and to identify a more effective strategy to measure engagement, we used a 

sequential, explanatory mixed methods study design where quantitative data were analyzed 

before qualitative data were collected to help explain results observed in the quantitative 

analyses. We initially conducted an environmental scan to provide background on: (1) the 

epidemiology of substance use, SUDs, and treatment; (2) factors associated with treatment 

initiation and engagement; (3) interventions designed to improve initiation and engagement; 

and (4) the development and use of the IET measure. The results of the scan informed both the 

quantitative and qualitative research that followed. The quantitative analyses relied on data 

from a large commercial health plan data set linked to geographic state-level market variables. 

Guided by the results of the quantitative analyses and the preparatory scan, we then undertook 

a series of qualitative case studies of health plans that were selected based on their 

performance on the IET measure and other critical characteristics (e.g., geographic 

distribution). This tripartite study design is depicted in Figure 5.

FIGURE 5. Tripartite Mixed Methods Study Design

Quantitative Methods 

Research Questions

The following research questions guided the quantitative analyses and include questions 

related to health plan and environmental factors regarding SUD treatment and OUD treatment.
38

Question 1: Do any of the following health plan factors affect initiation and/or engagement 

in alcohol or other SUD treatment?

a. Coverage of care continuum for SUD.

b. Out-of-pocket expenses for SUD treatment.

c. Reimbursement for outpatient and inpatient SUD treatment.

d. Percentage of population with an SUD.

e. Type of plan.

f. Plan beneficiary characteristics (age, sex, use of emergency department).

g. Number of beneficiaries.

Question 2: Do any of the following environmental factors affect a health plan’s performance 

on initiation and/or engagement in alcohol or other SUD treatment?

a. Provider availability.

b. State demographic profile (race/ethnicity, poverty).

c. Prevalence of alcohol or SUDs.

d. Attitudes toward SUD treatment.

e. Policies to reduce opioid prescriptions for pain.

Question 3: Do any of the following health plan factors affect the initiation and/or 

engagement in SUD treatment for individuals with OUDs?

a. Coverage of care continuum for SUD.

b. Out-of-pocket expenses for MAT.

c. Reimbursement for outpatient and inpatient SUD treatment and for MAT.

d. Receipt of MAT for OUDs.

e. Percentage of beneficiaries with OUD.

f. Type of plan.

g. Plan beneficiary characteristics (age, sex, use of emergency department).

h. Number of beneficiaries.

Question 4: Do any of the following environmental factors affect a health plan’s performance 

on initiation and/or engagement in SUD treatment for individuals with OUDs?

a. Availability of MAT providers.

b. State demographic profile (race/ethnicity, poverty).

c. Prevalence of OUDs.

d. State attitudes toward MAT as reflected in Medicaid coverage for all three medications 

for OUDs and SSA funding.

e. Policies to reduce opioid prescriptions for pain.

Data

For the quantitative analysis of factors associated with initiation and engagement among 

adults, we used the 2013-2014 Truven Health MarketScan® Commercial Claims and Encounters 

(CCAE) Research Database, linked to geographic information that provided state-level market 

characteristics. The MarketScan database is created from two sources: self-insured employers 
39

and regional health plans. For this study, we limited the data to those submitted by selfinsured employers because this information includes all behavioral health claims.

We linked several state-level variables to the health plan data to provide information about the 

environmental context in which the health plan functions. We linked the data using the state 

where most plan beneficiaries live. Our primary goal with these variables was to assess the 

following environmental characteristics: (1) provider availability; (2) underlying prevalence of 

alcohol and other substance disorders; (3) attitudes toward SUD treatment; and (4) state 

demographic characteristics. We considered several publicly available data sources to provide 

the environmental variables. The databases we selected to incorporate these characteristics 

are included in our description of covariates in Table 9.

Study Population 

The unit of analysis for this study is the employer health plan. Table 7 describes the number of 

employer health plans with more than 10, 20, 30, and 50 beneficiaries that met the 

denominator criteria for the IET measure. It also includes the number that met those 

denominator criteria if restricted to beneficiaries with OUDs. Because comparatively few plans 

had sufficient eligible beneficiaries with OUDs to allow meaningful analysis, we implemented a 

requirement for 20 or more cases (as is done in some CMS reporting practices) and used data 

from both 2013 and 2014. This allowed us to include 321 health plans in our larger analysis of 

the rates for SUD treatment, with a mean of 50,585 beneficiaries, and 82 plans for the analysis 

of the rates for OUD treatment, with a mean of 92,521 beneficiaries. Because the IET measure 

requires that an Index Episode Start Date (IESD) be established with a 60 day “clean period” 

immediately preceding the IESD, we also used data from the end of 2012 to assure a clean 

period for those with episodes beginning early in 2013. More information on the IESD and 

related clean period is provided in the methods summary of outcome variables.

TABLE 7. Number of Employer Health Plans with more than 10, 20, 30, and 50 Beneficiaries 

Meeting the Denominator Criteria for the IET Measure, Overall and Limited to Those with 

OUDs, 2013-2014

Measure More than 10 

Beneficiaries

More than 20 

Beneficiaries

More than 30 

Beneficiaries

More than 50 

Beneficiaries

Overall

Denominator 603 321 209 115

Limited to OUDs

Denominator 178 82 43 16

SOURCE: Truven Health MarketScan CCAE Research Database.

Beneficiary Population 

The beneficiary population for the health plans studied included all adults (aged 18 years and 

older) with an alcohol or other drug (AOD) diagnosis who were enrollees in the employer health 

plans that contributed data to the 2013-2014 MarketScan CCAE data. As discussed in greater 
40

detail below regarding the outcome variables, an IESD was established for that group; any 

adults who did not have a 60 day “clean period” prior to the IESD were excluded from the 

beneficiary population used for rate calculation. For the analyses that focused only on those 

with OUD disorders, the beneficiary population was further reduced to include only that subset 

of the larger group. 

Outcome Variables 

Four outcome variables were included in these analyses (Table 8). The outcome variables were 

derived from the commonly used measure of IET, discussed in greater detail below. 

TABLE 8. Outcome Variables

Variable Name Data Source Description

Initiation SUD MarketScan CCAE Database As specified in the IET measure for 

AOD dependence treatment initiationa

Engagement SUD MarketScan CCAE Database As specified in the IET measure for 

AOD dependence treatment 

engagement

Initiation OUD MarketScan CCAE Database Amended the specifications from the 

IET measure for AOD dependence 

treatment initiation so that it only 

included the services with OUD 

diagnoses for identification

Engagement OUD MarketScan CCAE Database Amended the specifications from the 

IET measure for AOD dependence 

treatment engagement so that it only 

included the services with OUD 

diagnoses for identification

a. NCQA. HEDIS & Quality Measurement, HEDIS Measures, HEDIS 2014, Volume 2: Technical 

Specifications. http://www.ncqa.org/hedis-quality-measurement/hedis-measures/hedis2014. 

The IET quality measure contains separate rates for initiation and engagement, with 

engagement measured among those who have initiated treatment. The IET quality measure 

defines initiation and engagement as follows:

 Initiation: the percentage of members who initiate treatment through an inpatient 

AOD admission, outpatient visit, IOP encounter, or partial hospitalization within 14 days 

of diagnosis.99

 Engagement: the percentage of members with a diagnosis of AOD dependence who 

initiated treatment and had two or more additional services with an AOD diagnosis 

within 30 days of the initiation visit.99
41

FIGURE 6. Initiation Rate Calculation Process

The initiation rate is the Initiation Numerator divided by the IET Denominator.a

IET Denominator

 Identify all members who were aged 18 years or older as of December 31 of the measurement 

year.

 For those members, identify the Index Episode (this establishes the IESD, or the date from which 

measurement occurs):

o Identify those who, during the Intake Period (on or between January 1 to November 15 of 

the measurement year), had at least 1 OP, IOP, PH, detoxification, or ED visit with an AOD 

diagnosis, or an acute or non-acute IP discharge with an AOD diagnosis or AOD procedure 

code with the discharge date during the Intake Period. Select the earliest of these visits 

during the Intake Period; this is the IESD.

 If the Index Episode is an IP event, the IESD is the date of discharge.

 If the Index Episode is an OP, IOP, PH, detoxification, or ED visit not resulting in an IP 

stay, the IESD is the date of service.

 If the Index Episode is an ED visit that results in an IP stay, the IP stay is the Index 

Episode and the IP discharge is the IESD.

 For direct transfers, the IESD is the discharge date from the last admission.

 Test for NDH (this establishes that there is a 60 day “clean period” with no visits or encounters 

related to AOD in the period before the Index Date):

o Exclude members with a claim or encounter with an AOD diagnosis during the 60 days 

before the IESD.

 For an IP IESD, use the admission date to determine the 60-day NDH period.

 For an ED visit resulting in an IP stay, use the ED date of service to determine the 

60-day NDH period.

 For direct transfers, use the first admission to determine the NDH period.

 Include those who were continuously enrolled for the 60 days prior to the IESD through 44 days 

after the IESD (105 today days) with no gap.

 Exclude those with an IP stay with a discharge date after December 1 of the measurement year.

Initiation Numerator

 Identify those in the denominator. From those, include the following as initiation compliant:

o If the Index Episode was an IP discharge, the person initiated.

o If the Index Episode was an OP, IOP, PH, detoxification, or ED visit, initiation occurs if 

there was an IP admission, another OP, IOP, or PH visit (but not detoxification) with an 

AOD diagnosis, on the IESD or in the 13 days after the IESD (14 days total).

 If the IESD and initiation visit are on the same day, they must be with different 

providers.

a. See https://www.qualitymeasures.ahrq.gov/summaries/summary/49778/engagement-of-alcoholand-other-drug-aod-treatment-percentage-of-members-who-initiated-treatment-and-who-hadtwo-or-more-additional-services-with-a-diagnosis-of-aod-within-30-days-of-the-initiation-visit. 

Access the NCQA website or Medicaid Adult Core Set website for related value sets.

In these analyses, each rate was used twice--first, to measure initiation and engagement in AOD 

dependence treatment and second, to measure initiation and engagement in OUD treatment 
42

for those health plan members with OUD diagnoses. Appendix B provides the list of diagnoses 

included for OUD and other SUD analyses.

The IET specifications used to measure initiation and engagement in this study are those that 

are published by NCQA as HEDIS measures, which may be obtained through the NCQA 

website.103 The NCQA specifications are similar to those used for the Medicaid Adult Core Set, 

although the Adult Core Set only applies to Medicaid enrollees and there are differences in the 

age ranges covered. The 2016 CMS Medicaid Adult Core Set is publicly available on the CMS 

website.105 The value sets that include the codes needed to calculate the measure also are 

located on the CMS website,145 or they may be acquired with the NCQA specification. 

Copyright considerations preclude including the NCQA specifications or the NCQA and Adult 

Core Set value sets as an appendix to this document. Figure 6 and Figure 7, however, depict the 

process of rate calculation for the IET measure.

FIGURE 7. Engagement Rate Calculation Process

The engagement rate is the Engagement Numerator divided by the IET Denominator.a

IET Denominator: Same as Denominator in Figure 6.

Engagement Numerator

 Identify those who were initiation compliant (see Figure 6). From those, include the 

following as engagement compliant:

o Engagement occurs if there were 2 or more IP admissions, OP IOP, or PH visits 

with an AOD diagnosis, beginning the day after the initiation encounter through 

29 days after the initiation (29 total days).

 If the 2 visits are on the same day, they must be with different providers to 

count as 2 visits.

 If initiation was via IP admission, the 29-day period begins the day after 

discharge.

a. See https://www.qualitymeasures.ahrq.gov/summaries/summary/49778/engagement-ofalcohol-and-other-drug-aod-treatment-percentage-of-members-who-initiated-treatmentand-who-had-two-or-more-additional-services-with-a-diagnosis-of-aod-within-30-days-ofthe-initiation-visit. Access the NCQA website or Medicaid Adult Core Set website for 

related value sets.

Covariates

We included covariates in our quantitative analyses that addressed five types of potential 

influences that were based on the results of our environmental scan, in which we examined the 

literature on factors that may promote or inhibit initiation and engagement in SUD treatment. 

These included: (1) health plan structure; (2) reimbursement factors; (3) benefit design; (4) plan 

beneficiary characteristics; and (5) state-level market and environmental characteristics. Table 

9 describes in detail the variables within each category.
43

TABLE 9. Covariates

Variable Name Data Source Description

Health Plan Structure

Plan type MarketScan CCAE Database Categorical variable indicating health plan 

structure as: (1) PPO; (2) HMO or capitated; or 

(3) high deductible health plan.a For 

regressions, PPO was the reference group.

Reimbursement Factors

MAT OOP MarketScan CCAE Database Median OOP cost per user for MAT 

medications for OUDs (paid by enrollee).b 

Outpatient OOP MarketScan CCAE Database Median OOP cost per user for SUD outpatient 

services, including IOP treatment and partial 

hospitalization services (paid by enrollee).

Inpatient OOP MarketScan CCAE Database Median OOP cost per user for SUD inpatient 

and residential services within health plan 

(paid by enrollee).

MAT reimbursement MarketScan CCAE Database Median reimbursement per user to pharmacy 

for MAT medications for OUDs (paid by 

enrollee and insurer).b 

Outpatient 

reimbursement 

MarketScan CCAE Database Median reimbursement per user to outpatient 

providers, including for IOP and partial

hospitalization services (paid by insurer).

Inpatient reimbursement MarketScan CCAE Database Median reimbursement per user to inpatient 

and residential providers for SUD services 

(paid by insurer). 

Benefit Design

MAT use MarketScan CCAE Database Categorical variable indicating percentage of 

beneficiaries with OUD who received: (1) no 

MAT; (2) buprenorphine/naloxone, extendedrelease naltrexone, or methadone (if coded in 

the claims) for 14 days or less (assumed to be 

for detox); or (3) buprenorphine/naloxone, XR 

naltrexone, or methadone for more than 14 

days (assumed to be for maintenance).b 

Residential MarketScan CCAE Database Boolean indicator that a health plan covers 

residential SUD services as evidenced by 

having at least one or more claims for each 

category of service. 

Intensive outpatient (IOP) 

or partial hospitalization 

services

MarketScan CCAE Database Benefit availability of IOP or partial 

hospitalization SUD services defined as the 

number of IOP or partial hospitalization 

services per plan beneficiary. 

Outpatient services MarketScan CCAE Database Benefit availability of outpatient SUD services 

defined as the number of outpatient SUD 

services per plan beneficiary. 
44

TABLE 9 (continued)

Variable Name Data Source Description

Health Plan Beneficiary Characteristics

SUD beneficiaries MarketScan CCAE Database Percentage of beneficiaries/member-years 

within health plan with either an identified 

SUD diagnosis on a medical claim (nonlaboratory and non-radiology) or receipt of 

MAT prescription. See Appendix C for the 

algorithm used to ascertain SUD 

beneficiaries.c 

OUD beneficiaries MarketScan CCAE Database Percentage of beneficiaries/member-years 

within health plan with either an identified 

OUD diagnosis on a medical claim (nonlaboratory and non-radiology) or receipt of a 

MAT prescription.b 

Ages 18-44 years MarketScan CCAE Database Percentage of beneficiaries in a plan who 

were within the age group of 18-44 years.

Female MarketScan CCAE Database Percentage of beneficiaries in a plan who 

were female.

ED use MarketScan CCAE Database Percentage of beneficiaries in a plan with an 

SUD (or OUD) who had: (1) 0 treat-andrelease ED visits with any diagnosis; (2) 1 

treat-and-release ED visit with any diagnosis; 

or (3) 2+ treat-and-release ED visits with any 

diagnosis. 

State-Level Market and Environmental Characteristicsd

SUD prevalence 2013-2014 NSDUH146 State-level data on the prevalence of alcohol 

and illicit drug abuse and dependence. 

Because health plans may have members in 

multiple states, the variable was the mean 

prevalence of the adult population with pastyear dependence on or abuse of illicit drugs or 

alcohol in states where health plan members 

reside.c 

Opioid prescriptions 2012 CDC infographic:

147 Number 

of opioid pain prescriptions per 

100 people by state

The infographic provided the number of 

opioid pain prescriptions by state per 100 

adults. Because health plans may have 

members in multiple states, the variable was 

the mean number of opioid pain prescriptions 

per 100 adults in states where health plan 

members reside.b 

SUD capacity 2013 N-SSATS148 The data provided the number of adults 

receiving treatment in SUD treatment 

facilities by state per 100,000 adults. Because 

health plans may have members in multiple 

states, the variable was the mean number of 

individuals receiving SUD specialty treatment 

per 100,000 adults in states where health plan 

members reside.c 
45

TABLE 9 (continued)

Variable Name Data Source Description

OTP capacity 2013 N-SSATS148 for methadone 

number

The data provided the number of OTP spaces 

available for methadone treatment by state 

per 100,000 adults. Because health plans may 

have members in multiple states, the variable 

was the mean number of OTP spaces available 

per 100,000 adults in states where health plan 

members reside.b 

Buprenorphine 

prescribers 

SAMHSA Buprenorphine Physician 

Locator149

US Census data for population 

aged 18 and over150

The buprenorphine locator identified the 

number of buprenorphine prescribers per 

state. The census data provided population 

aged 18 or older by state. Because health 

plans may have members in multiple states, 

the variable was the mean number of 

prescribers per 100,000 adults in states where 

health plan members reside.b 

Six MAT medications Medicaid Coverage and Financing 

of Medications to Treat Alcohol 

and OUDs (SAMHSA publication)25

The publication provided information on state 

Medicaid coverage of MAT medications as of 

2011-2012. The variable was the percentage 

of health plan members who live in a state 

that covers all 6 medications for alcohol and 

OUDs: disulfiram, acamprosate, methadone, 

buprenorphine/naloxone, naltrexone, and 

extended-release naltrexone.c 

Three MAT medications Medicaid Coverage and Financing 

of Medications to Treat Alcohol 

and OUDs (SAMHSA publication)25

The publication provided information on state 

Medicaid coverage of MAT medications as of 

2011-2012. The variable was the percentage 

of health plan members who live in a state 

that covers all 3 medications for OUDs: 

methadone, buprenorphine/naloxone, and 

naltrexone or extended-release naltrexone.b

Non-Hispanic White US Census data151 The census data provided the percentage of 

the population in each state who identified as 

non-minority (i.e., non-Hispanic White) versus 

minority. Because health plans may have 

members in multiple states, the variable was 

the mean percentage of the adult population 

that was non-Hispanic White in states where 

health plan members reside.

Poverty US Census data152 The census data provided the percentage of 

the population in each state who were below 

the 100 percent Federal Poverty Threshold. 

Because health plans may have members in 

multiple states, the variable was the mean 

percentage of the adult population that was 

below the poverty threshold in states where 

health plan members reside.
46

TABLE 9 (continued)

Variable Name Data Source Description

Private insurance US Census data153 The census data provided the percentage of 

the population in each state who have 

private, commercial insurance. Because 

health plans may have members in multiple 

states, the variable was the mean percentage 

of the adult population that has private 

insurance in states where health plan 

members reside.

PDMP 2015 Annual Review of PDMPs by 

the National Alliance for Model 

State Drug Laws154

State-level data that describe which states 

require prescribers and/or dispensers to 

access the PDMP in certain circumstances. 

The variable was the percentage of health 

plan members who live in one of the 24 states 

that required prescribers or dispensers to 

access the PDMP in certain circumstances in 

2014.

Single state authority 

(SSA) spending 

SAMHSA Publication: Funding and 

Characteristics of Single State 

Agencies for Substance Abuse 

Services and State Mental Health 

Agencies, 2013155

The data provide the total amount of SSA 

spending on SUDs by state per 100,000 adult 

population. Because health plans may have 

members in multiple states, the variable was 

the mean amount of SSA spending per 1,000 

adults in states where health plan members 

reside. 

a. Although plan type is self-reported, we verified that the self-report has a high match rate with health plan 

booklets.

b. This variable was used only in the second analyses related to OUDs.

c. This variable was used only in the first analyses and not the analyses related to OUDs.

d. In order to calculate the environmental and market characteristics that use state-specific data, each health 

plan member was attributed to a specific state of residence and each state characteristic was assigned to 

each beneficiary according to his or her state of residence. For discrete variables, we use the percentage of 

individuals who resided in states with that characteristic. For continuous variables, we calculated the mean 

for the health plan, based on the mean of the individuals that make up the plan. For example, if beneficiaries 

1-10 in health plan A lived in state X, then they were assigned the characteristics from state X. If 

beneficiaries 11-15 lived in state Y, then they were assigned the characteristics from state Y. The health plan 

variables were the mean of the beneficiaries’ market characteristics.

Analytic Approach

We calculated descriptive statistics separately, focusing on SUDs and OUDs. We examined 

characteristics of the health plan cohorts used for the overall SUD analysis and the more 

specific OUD analysis. We calculated mean initiation and engagement rates on the basis of 

health plan characteristics. For continuous variables, we calculated separate mean initiation 

and engagement rates for health plans that performed at or above the health plan mean and 

those that performed below the health plan mean. We examined plan characteristics by 

performance. For the SUD initiation and engagement measures, we divided the plans into 

tertiles on the basis of performance. For the OUD initiation and engagement measures, we 

divided the plans into those performing above the median (i.e., high performing plans) and 

those performing below the median (i.e., low performing plans). We then completed four 
47

multivariate regressions using general linear model analysis, examining the relationship 

between the covariates described above and the initiation and engagement measure 

outcomes. The separate regressions addressed initiation and engagement measure outcomes 

for SUD treatment and for OUD treatment alone.

Qualitative Methods 

Research Questions 

Three primary research questions guided the qualitative analyses to help us determine how 

successful health plans improve enrollee initiation and engagement in SUD and OUD treatment.

Question 1: Which types of health plan characteristics and strategies are demonstrated by 

plans with higher performance or greater improvement in IET in SUD and OUD treatment?

Question 2: What other factors (e.g., patient, setting, provider, state, and local market 

characteristics) do health plans identify as affecting rates of initiation and engagement in SUD 

and OUD treatment?

Question 3: What do health plan representatives believe are significant barriers and 

facilitators to initiating and engaging beneficiaries in SUD treatment?

Protocol and Discussion Guide Development 

To guide the health plan interviews, we developed a combined site visit protocol and discussion 

guide document. The protocol component of this document contains logistical information to 

prepare the research team for specific site visits. Protocol elements included a list of all 

interviewees and their health plan division, position titles, and contact information. The 

document also included a site visit agenda, which indicated how interviewees were grouped 

and the key focus of their specific interview session. The final pages of the protocol included 

useful background information for the research team conducting the site visit. This background 

provided an overview of the health plan, relevant news articles related to the plan, and the 

plan’s marketplace activity. This section also included information from documents sent by the 

plan prior to the site visit. The background information is described in further detail under 

Preliminary Data Collection.

We developed the discussion guide component of the document to identify facilitators and 

barriers to initiating or engaging health plan beneficiaries in SUD treatment. Major topic areas 

included health plan descriptive characteristics such as governance structure, benefit design, 

care models, reimbursement procedures and rates, network adequacy, and quality 

improvement methods; community and market characteristics such as state and Medicaid 

policies; patient factors such as use of MAT and attitudes and beliefs toward SUD treatment; 

provider characteristics such as billing proficiency, stigma toward SUD, outreach efforts, and 
48

use of evidence-based practices; and facilitators and barriers to initiation and engagement in 

treatment.

The guide includes semi-structured, open-ended interview questions to promote discussion and 

elicit the full range of potential responses from interviewees. Each semi-structured interview 

question includes a short list of optional probes to facilitate clarification and expand on the 

main question. Interview questions were designed to be flexible enough to allow the 

interviewer to stray from the guide if participant answers raise themes that the site visit lead 

deemed of value to the research questions. Following the first site visit, the research team 

made minor revisions to a few questions to promote a more natural language flow throughout 

the interview questions. The site visit protocol and discussion guide is attached as Appendix D.

Site Selection 

We selected health plans for site visits on the basis of their performance across various 

behavioral health measures reported in NCQA data. Health plan performance was based on the 

most recent data available, which differed for commercial and Medicaid plans. The study 

analyzed NQCA Quality Compass data for commercial plan performance between January 1, 

2015, and December 31, 2015, and for Medicaid plan performance between January 1, 2014, 

and December 31, 2014. The NCQA HEDIS measure data captures at least 75 percent of health 

plans in the United States.

Health plans initially were assessed on the basis of their HEDIS IET measure performance. The

research team stratified the 396 commercial plans to identify plans performing in the 95th

percentile on either the initiation (n=20) or engagement (n=20) measures. Among the 40 

commercial plans identified, 17 were selected for extremely high performance either on one of 

the two measures or on both. Only seven plans performed in the 95th percentile on both 

measures. We repeated the stratification process on the 182 Medicaid plans to identify top 

performers on initiation (n=10) and engagement (n=10) measures. A total of ten Medicaid 

plans were selected for high performance, although only four Medicaid plans were identified as 

top performers on both measures.

HEALTH PLAN SELECTION

We selected health plans for site visits on the basis of their performance 

across various behavioral health measures reported in NCQA data.

Top-performing commercial and Medicaid plans also were assessed for their performance 

across several other HEDIS behavioral health measures of interest, including: (1) antidepressant 

medication management for the effective acute and continuation phases of treatment; (2) 7-

day and 30-day follow-up after hospitalization for mental illness; and (3) mental health 

utilization of any IOP or partial hospitalization, or inpatient services. Additionally, we assessed 

two composite measures from the Consumer Assessment of Healthcare Providers and Systems 

(CAHPS) measurement set, including customer service and getting needed care.
49

We prioritized for site visit selection any commercial and Medicaid plans identified as 

performing in the top 5 percent for both components of the IET. We also prioritized for site 

visit selection health plans that performed well on only one component of the IET and also 

performed well across the other behavioral health measures. High performance on the 

antidepressant medication management acute phase and 7-day follow-up after hospitalization 

for mental illness measures was favored over high performance on the other behavioral health 

measures because of the immediacy of measured outreach. To ensure that the health plans 

selected for site visits reflected geographic and socioeconomic diversity, as well as differences 

in state health policy, the research team also considered the state in which the health plan was 

located--including whether it was operating in a Medicaid expansion state--and its total 

enrollment size. We identified for secondary outreach an additional group of commercial and 

Medicaid plans with slightly lower IET, behavioral health measure performance, or both, should 

the prioritized plans not agree to participate in the site visits. However, this group of plans was 

not outreached because the researchers were able to schedule visits with the prioritized plans.

There was one exception to the aforementioned site selection process. The researchers chose 

to include a Northwest Medicaid plan that was not included in the NQCA data but had a history 

of high IET performance. Additionally, the researchers were familiar with this plan’s 

organizational and incentive structure, which varied substantially from other Medicaid plans. 

We included the plan in an initial list of 12 plans (seven commercial, five Medicaid) prioritized 

for outreach. See Figure 8 for a visual depiction of the site selection process.

FIGURE 8. Health Plan Site Visit Selection Process

* One Medicaid health plan that did not appear in the NCQA data was included in the site visits due to their 

history of high performance and unique organizational and incentive structure.

Plan Recruitment 

Initial outreach to health plans was via email. A standard, brief description of the study was 

included in each initial email message. We sent multiple follow-up emails to initially 

unresponsive plans. When contact was established, we made a follow-up phone call to explain 
50

the study and site visit request. In several cases, the initial health plan representative with 

whom we spoke requested to hold multiple follow-up calls with us and other health plan staff 

members to gain site visit approval. Many health plans never responded to our outreach 

emails, and some with whom we spoke ultimately declined to participate in the study (Figure 

8). When a health plan did agree to participate in a site visit, we sent site visit agendas to the 

health plan contact describing which health plan representatives should be included in each 

group interview, and we used subsequent phone calls to clarify scheduling and participation. 

The researchers aimed to conduct six health plan site visits that included a mixture of 

commercial and Medicaid health plans. 

We planned site visits to include multiple natural group interviews including health plan 

executives (e.g., Chief Executive Officer, Chief Operating Officer, Chief Marketing Officer), 

managers (e.g., Director of Quality, Director of Behavioral Health, Director of Contracting, 

Director of Care Management), and front-line providers (e.g., care managers). The researchers 

aimed to conduct separate group interviews for health plan executives and leadership, 

behavioral health teams, quality improvement teams, and care management teams in an effort 

to reproduce the natural social and team dynamics in which health plan staff operate. 

Researchers anticipated that interviewee groupings would be based on the organizational 

structures of individual health plans. The researchers planned to design interview groupings in 

ways that would allow for: (1) duplicative questioning across different staffing groups; and (2) 

groups with common characteristics, such as health plan responsibilities or frequency of 

contact with plan beneficiaries, which would allow us to hone in on specific areas of interest. 

Preliminary Data Collection

Preliminary research. Researchers conducted preliminary research on health plans that were 

prioritized for site visits. Preliminary research included a limited Internet search of each health 

plan to identify basic plan information, including individuals in key leadership roles who should 

be included in outreach efforts. Once plans agreed to participate in preliminary calls to discuss 

the potential of study participation, the research team engaged in additional preliminary data 

collection.

Preliminary calls. Preliminary calls with health plans expressing interest in participating in a 

site visit provided valuable insight on health plan organization and an overview of quality 

improvement initiatives. The researchers inquired about the governance structure of the 

health plans to better identify key informants for the site visit interviews. Additionally, the 

researchers asked health plan contacts to provide a brief, general overview of health plan 

quality improvement efforts that occurred during the performance period or were ongoing at 

the time of the call. We used this information to inform the interview group schedule and to 

frame researcher’s semi-structured questions during the interviews. 

Plan-specific environmental scans. Prior to conducting the site visit, the research team 

performed a brief environmental scan of each health plan. These brief scans included reviews 

of the health plan website, plan publications including annual reports, and patient advisory 
51

reports. Such reviews yielded insight on health plan organizational structure, beneficiary 

population, and marketplace characteristics, including changes in Medicaid policy over time. 

The researchers also reviewed any recent news publications relevant to each plan. 

Data Collection During Site Visits

Two research team members jointly conducted qualitative, semi-structured group interviews in 

person with health plan affiliates. Each interview lasted approximately 90 minutes, and there 

were multiple 90-minute interviews for each plan. Each interview included a group of health 

plan personnel or related stakeholders, with interview groupings determined on the basis of 

area of expertise and inquiry. One of the research team members recorded detailed descriptive 

notes during the interview, while the other team member conducted the interview using the 

prepared interview protocol and guide. Both the notetaker and the interviewer reviewed notes 

from each interview for accuracy. The data presented are from notes and may not reflect 

verbatim quotes from the interviewees. 

Analytic Methods 

We imported all interview notes into NVivo 11 (QSR International), a qualitative data 

management program. The qualitative project lead analyzed interviews using a thematic 

framework analysis approach in combination with more inductive strategies of grounded 

theory to enable novel themes to emerge within the analysis. To develop initial parent-code

and subcode categories, we used constructs included in the theoretical model to explain 

participation in SUD treatment (Figure 1). The model describes four categories of factors 

hypothesized to affect initiation and engagement: (1) health plan factors; (2) market/

environmental factors; (3) individual patient-level factors; and (4) provider-level factors. Each 

of these four model components represented an original parent-code, populated with related 

subcodes. Using a partial grounded theory approach enabled the researchers to analyze the 

data inductively and to generate new theories about additional facilitators and barriers to 

initiation and engagement in SUD treatment that were not previously hypothesized in the 

conceptual framework. Through analysis, we identified multiple subcodes within the primary 

framework. We added one emergent parent-code to categorize comments specific to issues 

concerning IET measurement, including HEDIS criteria and costs associated with tracking and 

reporting on the HEDIS measures.

Consensus of the research team formed the basis for development of the initial codebook. One 

researcher used the codebook to systematically code interview notes. A senior researcher 

reviewed the coding. All coding discrepancies were reviewed by the research team and 

resolved by consensus decision. The inclusion of new codes and subcodes that emerged 

through the grounded approach also was conferred on and resolved by consensus within the 

research team. Appendix E provides the coding scheme that was developed. 
52

RESULTS 

Results of the quantitative and qualitative analyses are presented below. Because this is a 

mixed methods study in which quantitative results informed the subsequent qualitative 

analyses, the cross-cutting themes that emerged are elucidated in the Discussion section of this 

report.

Quantitative Results 

We address below the results of analyses related to IET measures for SUD treatment and OUD 

treatment. Tables referenced below are at the end of the text describing the quantitative 

results for SUD treatment.

IET Measures for SUD Treatment

Plan characteristics. A total of 321 health plans were included in the portion of the study that 

examined initiation and engagement in SUD treatment, with a mean beneficiary count of 

50,585 (Table 10). The majority (62.3 percent) of the plans were PPOs. Thirty percent of the 

plans covered residential services for SUD. On average, the number of IOP outpatient or partial 

hospitalization SUD services provided per beneficiary was 0.005, and the mean number of SUD 

outpatient services was 0.008. Mean median provider reimbursement for outpatient SUD 

services was $186.25 per user and for inpatient SUD services was $6529.62 per user. Mean 

median out-of-pocket costs per user for outpatient services was $54.01, and costs per user for 

inpatient services was $980.20.

Plan beneficiary characteristics. On average, less than 0.5 percent of beneficiaries in these 

employer health plans had an identified SUD (Table 10). Approximately 55 percent of 

beneficiaries were between the ages of 18 and 44 years, and nearly 52 percent were female. 

Among those with an identified SUD, most (53.85 percent) did not use the emergency 

department, while 22.36 percent used it once, and 23.79 percent used it two times or more 

during the study period. 

State-level market and environmental characteristics. Mean total state spending on the single 

state agency (SSA) for substance abuse services and state mental health per 1,000 members of 

the state population was $16,538.80 (Table 10). On average, the 67 percent of individuals in 

the states served by the plans identified as non-Hispanic White. Just under 20 percent lived 

below the poverty line and, on average, 66 percent of individuals in the states had private 

insurance. The mean past-year state prevalence rate of SUDs was slightly greater than 8 

percent, with 7 percent aged 18 years and older receiving SUD treatment per 1,000 individuals 

in the state population. Just over 40 percent of beneficiaries lived in states where all MAT 
53

medications for alcohol and OUDs were covered by Medicaid. Sixty-four percent lived in states 

that require prescribers or dispensers to access the state PDMP in certain circumstances. 

TABLE 10. Characteristics of Employer Health Plans Included in the Analysis

of NCQA IET Measures for SUD Treatment (N=321)

Health Plan Characteristics N % Mean

Number of beneficiaries --- --- 50584.60

Plan type

PPO 200.00 62.30 ---

HMO or capitated 60.00 18.70 ---

High deductible 61.00 19.00 ---

Reimbursement

OP-OOPa--- --- 54.01

IP-OOPb--- --- 980.20

OP reimbursementa--- --- 186.25

IP reimbursementb--- --- 6529.62

Benefit design

Residential 95.00 29.60 ---

IOP/PH services --- --- 0.0047

OP services --- --- 0.0075

Beneficiary characteristics

SUD beneficiaries --- --- 0.43

Age 18-44 years --- --- 55.06

Female --- --- 51.81

ED use

0 times --- --- 53.85

1 time --- --- 22.36

2 or more times --- --- 23.79

Market characteristics

SUD prevalence --- --- 8.38

SUD capacity --- --- 7.34

6 MAT medications --- --- 40.30

Non-Hispanic White --- --- 66.79

Poverty --- --- 19.87

Private insurance --- --- 66.01

PDMP --- --- 63.90

SSA spending --- --- 16358.80

SOURCE: Truven Health MarketScan CCAE data, 2013-2014.

a. Outpatient services include IOP services and partial hospitalization services in addition to other 

outpatient services.

b. Inpatient services include inpatient and residential services.

Initiation variable skewness = -0.0627346; Initiation variable kurtosis = 0.27721992.

Engagement variable skewness = 0.85848228; Engagement variable kurtosis = 0.67542441.

Mean NCQA IET measures by health plan characteristics. The mean SUD treatment initiation 

rate for the health plans studied was 0.53, and the mean engagement rate was 0.14 (Table 11). 

Initiation and engagement rates did not differ greatly between plan types, although they 

tended to be somewhat lower in HMO or capitated plans than in either PPOs or high-deductible 

plans. Plans covering residential services had a marginally higher rate of initiation but not 
54

engagement. Plans that were equal to or above the mean in terms of numbers of IOP or partial 

hospitalization SUD services (initiation 0.58 vs 0.50; engagement 0.21 vs. 0.11) and SUD 

outpatient services (initiation 0.57 vs. 0.51; engagement 0.18 vs. 0.12) had higher initiation and 

engagement rates than plans that were below the mean in the provision of those services. 

Similarly, those with higher median out-of-pocket costs for SUD outpatient services (initiation 

0.55 vs. 0.51; engagement 0.15 vs. 0.14) and higher median provider reimbursement for 

outpatient SUD services (initiation 0.57 vs. 0.51; engagement 0.18 vs. 0.12) had higher initiation 

and engagement rates compared with those below the mean in out-of-pocket costs and 

provider reimbursement for outpatient SUD services. These findings on out-of-pocket cost 

(initiation 0.52 vs. 0.53; engagement 0.14 vs. 0.15) and reimbursement (initiation 0.52 vs. 0.53; 

engagement 0.14 vs. 0.15) were reversed for inpatient services.

Mean NCQA IET measures by plan beneficiary characteristics. In health plans with a mean or 

above mean percentage of beneficiaries with an identified SUD, the mean SUD treatment 

initiation rate (0.56 vs. 0.51) was higher, as was the mean engagement rate (0.16 vs. 0.13), 

compared with plans that had fewer of these beneficiaries (Table 11). There were few or no 

differences in rates related to emergency department use or age, although engagement rates 

were higher in plans where the percentage of beneficiaries aged 18-44 years was equal to or 

above the mean (0.15 vs. 0.13). Where the percentage of female beneficiaries was equal to or 

above the mean, rates of both initiation and engagement were lower (initiation 0.51 vs. 0.54; 

engagement 0.12 vs. 0.16).

TABLE 11. Mean NCQA IET Measures for SUD Treatment

by Employer Health Plan Characteristics (N=321)

Health Plan Characteristics Initiation Rate

Mean Rate

Engagement Rate 

Mean Rate

Measure rate 0.53 0.14

Plan type

PPO 0.53 0.14

HMO or capitated 0.51 0.14

High deductible 0.52 0.14

Reimbursement

OP-OOPa

Plans equal to or above mean 0.55 0.15

Plans below mean 0.51 0.14

IP-OOPb

Plans equal to or above mean 0.52 0.14

Plans below mean 0.53 0.15

OP reimbursementa

Plans equal to or above mean 0.57 0.18

Plans below mean 0.51 0.12

IP reimbursementb

Plans equal to or above mean 0.52 0.14

Plans below mean 0.53 0.15
55

TABLE 11 (continued)

Health Plan Characteristics Initiation Rate

Mean Rate

Engagement Rate 

Mean Rate

Benefit design

Residential 0.54 0.14

IOP/PH services

Plans equal to or above mean 0.58 0.21

Plans below mean 0.50 0.11

OP services

Plans equal to or above mean 0.57 0.18

Plans below mean 0.51 0.12

Beneficiary characteristics

SUD beneficiaries

Plans equal to or above mean 0.56 0.16

Plans below mean 0.51 0.13

Age 18-44 years 

Plans equal to or above mean 0.53 0.15

Plans below mean 0.53 0.13

Female

Plans equal to or above mean 0.51 0.12

Plans below mean 0.54 0.16

ED use >2 times

Plans equal to or above mean 0.53 0.14

Plans below mean 0.52 0.14

Market characteristics

SUD prevalence 

Plans equal to or above mean 0.51 0.14

Plans below mean 0.55 0.14

SUD capacity

Plans equal to or above mean 0.52 0.14

Plans below mean 0.53 0.14

Six MAT medications 

Plans equal to or above mean 0.54 0.14

Plans below mean 0.52 0.14

Non-Hispanic White

Plans equal to or above mean 0.54 0.16

Plans below mean 0.51 0.13

Poverty

Plans equal to or above mean 0.53 0.14

Plans below mean 0.53 0.15

Private insurance

Plans equal to or above mean 0.55 0.16

Plans below mean 0.50 0.13

PDMP 

Plans equal to or above mean 0.53 0.15

Plans below mean 0.53 0.13
56

TABLE 11 (continued)

Health Plan Characteristics Initiation Rate

Mean Rate

Engagement Rate 

Mean Rate

SSA spending 

Plans equal to or above mean 0.52 0.14

Plans below mean 0.53 0.15

SOURCE: Truven Health MarketScan CCAE data, 2013-2014.

a. Outpatient services include IOP services and partial hospitalization services in addition to 

other outpatient services.

b. Inpatient services include inpatient and residential services.

Mean NCQA IET measures by state-level market and environmental characteristics. 

Differences in initiation and engagement rates between plans equal to or above versus below 

the mean were minimal related to total state spending on the SSA, percentage of the 

population below the poverty line, and number of beneficiaries 18 years or older receiving SUD 

treatment relative to the state population (Table 11). However, when the state past-year 

prevalence of SUDs was equal to or above the mean, initiation rates were lower (0.51 vs. 0.55). 

In contrast, initiation rates were higher if a plan was in a state where all MAT medications for 

alcohol and OUDs were covered by Medicaid (0.54 vs. 0.52), a mean or above mean percentage 

of the population was non-Hispanic White (0.54 vs. 0.51), or a mean or above mean percentage 

of the population had private insurance (0.55 vs. 0.50). Engagement rates were higher if a plan 

was in a state where a mean or above mean percentage of the population was non-Hispanic 

White (0.16 vs. 0.13), a mean or above mean percentage of the population had private 

insurance (0.16 vs. 0.13), or where prescribers or dispensers were required to access the PDMP 

in certain circumstances (0.15 vs. 0.13). 

Characteristics by performance on the NCQA initiation measure. Health plans were divided 

into tertiles on the basis of performance on the initiation measure, with mean rates for the 

lowest tertile at 0.41, for the middle tertile 0.53, and for the highest tertile 0.64 (Table 12). 

Compared with low performers, middle and high performers tended to be PPOs. Low 

performers were less apt to cover residential services and provided far fewer SUD IOP, partial 

hospitalization, or outpatient SUD services than did middle and high performers. The mean 

number of IOP or partial hospitalization services per beneficiary ranged from 0.0026 for low 

performers to 0.0075 for high performers, with the mean number of outpatient services 

ranging from 0.0051 for low performers to 0.0114 for high performers. Similarly, out-of-pocket 

outpatient costs were higher for high performers ($58.82) compared with low performers 

($45.64), as was outpatient reimbursement ($244.87 vs. $161.79). Both inpatient out-of-pocket 

costs ($856.24 vs. $1055.87) and reimbursement to providers ($6248.28 vs. $7167.33) were far 

lower for plans that performed in the upper tertile compared with those in the lowest tertile. 

Compared with the lowest performing plans, plans that were highest performing on initiation 

had more beneficiaries identified with SUDs (0.52 percent vs. 0.39 percent) (Table 12). They 

also had lower percentages of beneficiaries aged 18-44 years (53.33 percent vs. 55.25 percent). 

The most pronounced market or environmental characteristics that differed between the 
57

lowest and highest tertile plans were: (1) mean total state spending on the SSA (higher for low 

performing plans); (2) mean percentage of individuals in the state who were non-Hispanic 

White (lower for low performing plans); and (3) mean percentage of individuals in the state 

with private insurance (lower for low performing plans).

TABLE 12. Employer Health Plan Characteristics by Performance on

the NCQA Initiation Measure for SUD Treatment (N=107)

Health Plan Characteristic

Lowest 

Tertile 

Performers

N/Mean

Lowest 

Tertile 

Performers

%

Middle 

Tertile 

Performers

N/Mean

Middle 

Tertile 

Performers

%

Highest 

Tertile 

Performers

N/Mean

Highest 

Tertile 

Performers

%

Initiation measure rate 0.41 --- 0.53 --- 0.64 ---

Number of beneficiaries 46811.60 --- 65667.40 --- 39274.70 ---

Plan type

PPO 59.00 55.10 74.00 69.20 67.00 62.60

HMO or capitated 26.00 24.30 12.00 11.20 22.00 20.60

High deductible 22.00 20.60 21.00 19.60 18.00 16.80

Reimbursement

OP-OOPa45.64 --- 57.56 --- 58.82 ---

IP-OOPb1055.87 --- 1028.50 --- 856.24 ---

OP reimbursementa161.79 --- 152.10 --- 244.87 ---

IP reimbursementb7167.33 --- 6173.26 --- 6248.28 ---

Benefit design

Residential 27.00 25.20 37.00 34.60 31.00 29.00

IOP/PH services 0.0026 --- 0.0039 --- 0.0075 ---

OP services 0.0051 --- 0.0061 --- 0.0114 ---

Beneficiary characteristics

SUD beneficiaries 0.39 --- 0.38 --- 0.52 ---

Age 18-44 years 55.25 --- 56.61 --- 53.33 ---

Female 52.02 --- 51.81 --- 51.59 ---

ED use

0 times 54.91 --- 53.33 --- 53.32 ---

1 time 21.85 --- 22.86 --- 22.36 ---

2 or more times 23.25 --- 23.81 --- 24.32 ---

Market characteristics

SUD prevalence 8.42 --- 8.37 --- 8.34 ---

SUD capacity 7.46 --- 7.46 --- 7.10 ---

6 MAT medications 43.15 --- 33.92 --- 43.83 ---

Non-Hispanic White 62.90 --- 66.89 --- 70.57 ---

Poverty 19.71 --- 20.06 --- 19.83 ---

Private insurance 65.22 --- 65.58 --- 67.24 ---

PDMP 61.39 --- 67.94 --- 62.36 ---

SSA spending 17307.40 --- 15781.50 --- 15987.50 ---

SOURCE: Truven Health MarketScan CCAE data, 2013-2014.

a. Outpatient services include IOP services and partial hospitalization services in addition to other outpatient services.

b. Inpatient services include inpatient and residential services.

Characteristics by performance on the NCQA engagement measure. Health plans also were 

divided into tertiles on the engagement measure for SUD services, with mean rates for the 

lowest tertile at 0.05, the middle tertile at 0.13, and the highest tertile at 0.25 (Table 13). The 

lowest performing plans had the highest mean number of beneficiaries. Middle and high tertile 

plans were PPOs to a greater extent than were low performing plans. There were no 

substantial differences in initiation rates depending on the provision of residential SUD services 

by the plans. The mean number of IOP or partial hospitalization services per beneficiary ranged 

from 0.0021 for low performers to 0.0083 for high performers, with the mean number of 

outpatient services ranging from 0.0051 for low performers to 0.0117 for high performers. 
58

Differences in reimbursement characteristics were greatest for median provider 

reimbursement for outpatient SUD services per user (low performing $137.50 vs. high $271.19), 

for median provider reimbursement for inpatient SUD services per user (low performing 

$7239.56 vs. high $6268.03), and for median out-of-pocket costs for inpatient SUD services per 

user (low performing $996.45 vs. high $965.03). 

TABLE 13. Employer Health Plan Characteristics by Performance on

the NCQA Engagement Measure for SUD Treatment (N=107)

Health Plan Characteristic

Lowest 

Tertile 

Performers

N/Mean

Lowest 

Tertile 

Performers

%

Middle 

Tertile 

Performers

N/Mean

Middle 

Tertile 

Performers

%

Highest 

Tertile 

Performers

N/Mean

Highest 

Tertile 

Performers

%

Engagement measure rate 0.05 --- 0.13 --- 0.25 ---

Number of beneficiaries 56568.50 --- 49913.70 --- 45271.50 ---

Plan type

PPO 57.00 53.30 77.00 72.00 66.00 61.70

HMO or capitated 29.00 27.10 11.00 10.30 20.00 18.70

High deductible 21.00 19.60 19.00 17.80 21.00 19.60

Reimbursement

OP-OOPa50.72 --- 55.57 --- 55.73 ---

IP-OOPb996.45 --- 979.12 --- 965.03 ---

OP reimbursementa137.50 --- 150.06 --- 271.19 ---

IP reimbursementb7239.56 --- 6081.28 --- 6268.03 ---

Benefit design

Residential 31.00 29.00 32.00 29.90 32.00 29.90

IOP/PH services 0.0021 --- 0.0034 --- 0.0083 ---

OP services 0.0051 --- 0.0058 --- 0.0117 ---

Beneficiary characteristics

SUD beneficiaries 0.41 --- 0.41 --- 0.47 ---

Age 18-44 years 54.98 --- 54.38 --- 55.83 ---

Female 52.11 --- 52.70 --- 50.61 ---

ED use

0 times 53.84 --- 53.77 --- 53.94 ---

1 time 22.45 --- 22.66 --- 21.96 ---

2 or more times 23.71 --- 23.57 --- 24.10 ---

Market characteristics

SUD prevalence 8.42 --- 8.30 --- 8.41 ---

SUD capacity 8.01 --- 6.83 --- 7.19 ---

6 MAT medications 45.83 --- 34.99 --- 40.07 ---

Non-Hispanic White 62.76 --- 67.67 --- 69.94 ---

Poverty 19.88 --- 20.08 --- 19.64 ---

Private insurance 65.16 --- 65.96 --- 66.92 ---

PDMP 60.94 --- 64.39 --- 66.36 ---

SSA spending 17040.60 --- 15534.40 --- 16501.50 ---

SOURCE: Truven Health MarketScan CCAE data, 2013-2014.

a. Outpatient services include IOP services and partial hospitalization services in addition to other outpatient services.

b. Inpatient services include inpatient and residential services.

Major differences in beneficiary characteristics were not seen between plans at different levels 

of performance (Table 13). Compared with middle performing plans, market and 

environmental characteristics often were more similar between low and high performing plans. 

However, the highest tertile performers also had higher percentages of beneficiaries living in 

states requiring prescribers or dispensers to access the PDMP (low performing 60.94 percent 

vs. high 66.36 percent) and higher percentages of individuals living in states with a higher 

percentage of non-Hispanic White population (high performing 69.94 percent vs. 62.76 

percent). 
59

TABLE 14. Multivariate Regression Results Examining the Effect of Health Plan

and Environmental Characteristics on Employer Health Plan Performance on

the NCQA IET Measures for SUD Treatment (N=321)

Health Plan Characteristics

Initiation

Measure

Beta

Initiation 

Measure

p-value

Engagement 

Measure

Beta

Engagement 

Measure

p-value

Number of beneficiaries 6.21E-08 0.4523 -4.1E-09 0.9528

Plan type

PPO Reference Reference Reference Reference

HMO or capitated -0.01858 0.2345 -0.00948 0.4723

High deductible -0.00244 0.8674 -0.00386 0.7541

Reimbursement

OP-OOPa0.000517 0.0007 9.13E-05 0.4774

IP-OOPb-9.8E-06 0.1948 -4.5E-06 0.4846

OP reimbursementa-1.1E-05 0.6301 2.8E-06 0.8869

IP reimbursementb1.92E-06 0.2331 3.42E-07 0.8014

Benefit design

Residential 0.0101 0.409 0.000302 0.9766

IOP/PH services 2.06408 0.0103 3.82326 <0.0001

OP services 1.45792 0.1467 4.13869 <0.0001

Beneficiary characteristics

SUD beneficiaries 7.43985 0.0573 -12.6598 0.0001

Age 18-44 years -0.01623 0.7253 -0.00937 0.8102

Female -0.07323 0.5486 -0.20293 0.0497

ED use

0 times Reference Reference Reference Reference

1 time 0.14589 0.2275 -0.12134 0.2347

2 or more times -0.11496 0.192 -0.08526 0.2518

Market characteristics

SUD prevalence -0.00705 0.68 0.00706 0.6247

SUD capacity -0.00071 0.5954 -0.00138 0.2233

Six MAT medications 0.00639 0.763 -0.00641 0.7201

Non-Hispanic White 0.00248 0.0001 0.0017 0.0019

Poverty 0.00178 0.5746 0.000502 0.8514

PDMP -0.02494 0.2341 0.01716 0.3322

SSA spending -1.5E-06 0.172 1.56E-07 0.8691

SOURCE: Truven Health MarketScan CCAE data, 2013-2014

a. Outpatient services include IOP services and partial hospitalization services in addition to other outpatient 

services.

b. Inpatient services include inpatient and residential services.

Initiation measure regression r2: 0.2609.

Engagement measure regression r2: 0.3476.

Results of multivariate analysis on characteristics influencing initiation and engagement. 

Characteristics significantly associated with higher rates of SUD treatment initiation among 

employer health plans included providing higher numbers of IOP and partial hospitalization 

services per beneficiary (β = 2.06408, p = 0.0103), having higher than the mean median out-ofpocket costs for outpatient SUD services per user (β = 0.000517, p = 0.0007), and being in a 

state with a higher percentage of individuals who were non-Hispanic White (β = 0.00248, p = 

0.0001). (Table 14).
60

Higher rates of SUD treatment engagement were associated with: (1) providing higher numbers 

of SUD IOP and partial hospitalization services per beneficiary (β = 3.82326, p <0.0001); (2) 

providing higher numbers of SUD outpatient services per beneficiary (β = 4.13869, p <0.0001);

and (3) being in a state with a higher percentage of individuals who were non-Hispanic White (β 

= 0.0017, p = 0.0019). Higher rates of engagement were negatively associated with having 

more beneficiaries in the plan with an identified SUD (β = -12.6598, p = 0.0001) and more 

beneficiaries who are female (β = -0.20293, p = 0.0497). 

IET Measures for OUD Treatment

Plan characteristics. A total of 82 health plans were included in the portion of the study that 

examined initiation and engagement rates for those with identified OUDs, with a mean 

beneficiary count of 92,521 (Table 15). The majority (66 percent) of the plans were PPOs. 

Approximately 37 percent of the plans covered residential services. On average, the number of 

IOP or partial hospitalization SUD services provided per beneficiary was 0.005 and the mean 

number of SUD outpatient services was 0.009. Among those beneficiaries with identified OUD, 

53 percent did not receive MAT, 3 percent received it for 14 days or less, and 44 percent 

received it for more than 14 days. Mean median provider reimbursement for outpatient SUD 

services was $181.83 per user, for inpatient SUD services was $5656.22 per user, and for MAT 

was $2292.98 per user. Mean median out-of-pocket cost per user for outpatient services was 

$47.51, mean median cost per user for inpatient services was $767.80, and mean median cost 

per user for MAT medications was $302.26.

Plan beneficiary characteristics. On average, less than 0.29 percent of beneficiaries in these 

employer health plans had an identified OUD (Table 15). Approximately 54 percent of 

beneficiaries were between the ages of 18 and 44 years, and nearly 52 percent were female. 

Among those with an SUD, most (55.6 percent) did not use the emergency department, while 

20.7 percent used it once, and 23.7 percent used it two times or more during the study period.

State-level market and environmental characteristics. For this smaller subset of health plans, 

mean total state spending on the SSA per 1,000 members of the state population was 

$16,325.90 (Table 15). On average, 68 percent of individuals in the states served by the plans 

identified as being non-Hispanic White. Just over 20 percent lived below the poverty line and, 

on average, 66 percent of individuals in the state had private insurance. The mean past-year 

state prevalence rate of opioid prescriptions was 93.5 per 100 individuals in the state, with 7 

percent aged 18 years and older receiving SUD treatment per 1,000 individuals in the state 

population. Fifty-two percent of beneficiaries lived in states where all three MAT medications 

for OUD were covered by Medicaid. Sixty-eight percent lived in states that require prescribers 

or dispensers to access the state PDMP in certain circumstances. There were approximately 

144 OTP spaces available for methadone per 100,000 population in the states, and the mean 

number of buprenorphine prescribers per 100,000 population was eight.
61

TABLE 15. Characteristics of Employer Health Plans Included in the Analysis of

NCQA IET Measures, Limited to OUDs (N=82)

Health Plan Characteristic N % Mean

Number of beneficiaries --- --- 92521.10

Plan type

PPO 54.00 65.90 ---

HMO or capitated 16.00 19.50 ---

High deductible 12.00 14.60 ---

Reimbursement

MAT OOP --- --- 302.26

OP-OOPa--- --- 47.51

IP-OOPb--- --- 767.80

MAT reimbursement --- --- 2292.98

OP reimbursementa--- --- 181.83

IP reimbursementb--- --- 5656.22

Benefit design

MAT use

None --- --- 0.53

14 days or less --- --- 0.03

>14 days --- --- 0.44

Residential 30.00 36.60 ---

IOP/PH services --- --- 0.0053

OP services --- --- 0.0090

Beneficiary characteristics

OUD beneficiaries --- --- 0.29

Age 18-44 years --- --- 53.90

Female --- --- 51.91

ED use

0 times --- --- 55.61

1 time --- --- 20.65

2 or more times --- --- 23.74

Market characteristics

Opioid prescriptions --- --- 93.46

SUD capacity --- --- 7.21

OTP capacity --- --- 143.63

Buprenorphine prescribers --- --- 8.26

3 MAT --- --- 52.00

Non-Hispanic White --- --- 68.27

Poverty --- --- 20.33

Private insurance --- --- 66.11

PDMP --- --- 67.95

SSA spending --- --- 16325.90

SOURCE: Truven Health MarketScan CCAE data, 2013-2014.

a. Outpatient services include IOP services and partial hospitalization services in addition to other 

outpatient services.

b. Inpatient services include inpatient and residential services.

Initiation variable skewness = 0.47826139; Initiation variable kurtosis = 0.16101831.

Engagement variable skewness = 0.51762313; Engagement variable kurtosis = -0.2974445.
62

Mean NCQA IET measures by health plan characteristics. The mean initiation rate for OUD 

treatment for the health plans was 0.55, and the mean engagement rate for OUD treatment 

was 0.15 (Table 16). Both initiation and engagement rates tended to be higher in PPO plans, 

particularly compared with high deductible plans (initiation 0.56 vs. 0.51; engagement 0.16 vs. 

0.13). Plans covering residential services had a slightly higher rate of initiation (0.57) and 

engagement (0.16) compared with the mean per plan. Plans that were equal to or above the 

mean in terms of numbers of IOP or partial hospitalization SUD services (initiation 0.61 vs 0.51; 

engagement (0.20 vs. 0.13) and SUD outpatient services (initiation 0.60 vs. 0.52; engagement 

0.20 vs. 0.13) had higher initiation and engagement rates than plans that were below the mean 

in the provision of those services. Plans that were above the mean percentage of beneficiaries 

with OUDs who received MAT in excess of 14 days did not have higher initiation rates 

compared with plans with a lower percentage of beneficiaries meeting these characteristics 

who did have higher engagement rates (0.17 vs. 0.13). Compared with plans below the mean in 

out-of-pocket costs and provider reimbursement for outpatient services, plans with higher 

median out-of-pocket costs for SUD outpatient services had marginally lower initiation rates 

but higher engagement rates (initiation 0.54 vs. 0.55; engagement 0.16 vs. 0.15), and plans with 

higher median provider reimbursement for outpatient SUD services (initiation 0.58 vs. 0.53; 

engagement 0.19 vs. 0.13) had higher initiation and engagement rates. Health plans with mean 

or above mean out-of-pocket costs (initiation 0.53 vs. 0.56; engagement 0.14 vs. 0.17) or 

provider reimbursement (initiation 0.54 vs. 0.55; engagement 0.14 vs. 0.16) for inpatient 

services had lower rates for both initiation and engagement. Health plans that had mean or 

above mean pharmacy reimbursement for MAT showed both higher initiation (0.58 vs. 0.52) 

and engagement (0.16 vs. 0.15) rates compared with those with pharmacy reimbursement 

below the mean. When median out-of-pocket costs were equal to or above the mean for MAT 

medications, initiation rates were lower (0.53 vs. 0.56) and engagement rates higher (0.16 vs. 

0.15) compared with plans with lower out-of-pocket costs.

TABLE 16. Mean NCQA IET Measures by Employer Health Plan Characteristics,

Limited to OUDs (N=41)

Health Plan Characteristic Initiation Rate

Mean Rate

Engagement Rate

Mean Rate

Measure rate 0.55 0.15

Plan type

PPO 0.56 0.16

HMO or capitated 0.53 0.15

High deductible 0.51 0.13

Reimbursement

MAT OOP 

Plans equal to or above mean 0.53 0.16

Plans below mean 0.56 0.15

OP-OOPa

Plans equal to or above mean 0.54 0.16

Plans below mean 0.55 0.15
63

TABLE 16 (continued)

Health Plan Characteristic Initiation Rate

Mean Rate

Engagement Rate

Mean Rate

IP-OOPb

Plans equal to or above mean 0.53 0.14

Plans below mean 0.56 0.17

MAT reimbursement 

Plans equal to or above mean 0.58 0.16

Plans below mean 0.52 0.15

OP reimbursementa

Plans equal to or above mean 0.58 0.19

Plans below mean 0.53 0.13

Median provider reimbursement for 

inpatient SUD servicesb

Plans equal to or above mean 0.54 0.14

Plans below mean 0.55 0.16

Benefit design

MAT use >14 days

Plans equal to or above mean 0.55 0.17

Plans below mean 0.55 0.13

Residential services 0.57 0.16

IOP/PH services

Plans equal to or above mean 0.61 0.20

Plans below mean 0.51 0.13

OP services

Plans equal to or above mean 0.60 0.20

Plans below mean 0.52 0.13

Beneficiary characteristics

OUD beneficiaries

Plans equal to or above mean 0.58 0.15

Plans below mean 0.52 0.15

Age 18-44 years

Plans equal to or above mean 0.54 0.17

Plans below mean 0.55 0.14

Female

Plans equal to or above mean 0.52 0.12

Plans below mean 0.57 0.18

ED use 2 times or more 

Plans equal to or above mean 0.58 0.17

Plans below mean 0.52 0.13

Market characteristics

Opioid prescriptions 

Plans equal to or above mean 0.59 0.18

Plans below mean 0.51 0.13
64

TABLE 16 (continued)

Health Plan Characteristic Initiation Rate

Mean Rate

Engagement Rate

Mean Rate

SUD capacity

Plans equal to or above mean 0.51 0.14

Plans below mean 0.57 0.16

OTP capacity

Plans equal to or above mean 0.53 0.14

Plans below mean 0.56 0.16

Buprenorphine prescribers 

Plans equal to or above mean 0.55 0.16

Plans below mean 0.54 0.15

3 MAT medications

Plans equal to or above mean 0.59 0.17

Plans below mean 0.52 0.14

Non-Hispanic White

Plans equal to or above mean 0.59 0.18

Plans below mean 0.52 0.13

Poverty

Plans equal to or above mean 0.55 0.15

Plans below mean 0.54 0.16

Private insurance

Plans equal to or above mean 0.59 0.17

Plans below mean 0.50 0.13

PDMP 

Plans equal to or above mean 0.52 0.15

Plans below mean 0.58 0.16

SSA spending 

Plans equal to or above mean 0.55 0.16

Plans below mean 0.54 0.14

SOURCE: Truven Health MarketScan CCAE data, 2013-2014.

a. Outpatient services include IOP services and partial hospitalization services in addition to 

other outpatient services.

b. Inpatient services include inpatient and residential services.

Mean NCQA IET measures by plan beneficiary characteristics. In health plans with a mean or 

above mean percentage of beneficiaries with an identified OUD, the mean initiation rate (0.58 

vs. 0.52) was higher compared with plans with fewer beneficiaries with these characteristics, 

while there were no differences for engagement (Table 16). Both initiation (0.58 vs. 0.52) and 

engagement (0.17 vs. 0.13) rates were higher in plans with mean to above mean percentages of 

beneficiaries with OUD who used the emergency department two or more times. Engagement 

rates were higher in plans where the percentage of beneficiaries aged 18-44 years was equal to

or above the mean (0.17 vs. 0.14). Where the percentage of female beneficiaries was equal to 

or above mean, rates of both initiation and engagement were lower (initiation 0.52 vs. 0.57; 

engagement 0.12 vs. 0.18).
65

Mean NCQA IET measures by state-level market and environmental characteristics. Initiation 

and engagement rates for OUD treatment were somewhat higher for plans in states where 

total state spending on the SSA was equal to or above the mean (initiation 0.55 vs. 0.54; 

engagement 0.16 vs. 0.14) and where the number of buprenorphine prescribers per 100,000 

state population was equal to or above the mean (initiation 0.55 vs. 0.54; engagement 0.16 vs. 

0.15) (Table 16). Both rates were quite a bit higher for plans in states that were equal to or 

above the mean for prevalence of opioid prescriptions per 100 people (initiation 0.59 vs. 0.51; 

engagement 0.18 vs. 0.13), states where all three OUD MAT medications were covered by 

Medicaid (initiation 0.59 vs. 0.52; engagement 0.17 vs. 0.14), where the percentage of the nonHispanic White population was higher (initiation 0.59 vs. 0.52; engagement 0.18 vs. 0.13), and 

where more of the population had private insurance (initiation 0.59 vs. 0.50; engagement 0.17 

vs. 0.13). Where the number of beneficiaries aged 18 or older receiving SUD treatment per 

1,000 population was at or above mean, both initiation and engagement rates were lower 

(initiation 0.51 vs. 0.57; engagement 0.14 vs. 0.16); the same was true where the number of 

OTP spaces for methadone was greater (initiation 0.53 vs. 0.56; engagement 0.14 vs. 0.16). 

Similarly, both initiation and engagement rates were lower if a plan was in a state where 

prescribers or dispensers were required to access the PDMP in certain circumstances (initiation 

0.52 vs. 0.58; engagement 0.15 vs. 0.16).

Characteristics by performance on the NCQA initiation measure. Health plans were divided 

into low and high performers on the basis of rates of OUD initiation, with mean initiation rates 

for low performers of 0.50 and for high performers of 0.59 (Table 17). Low performers tended 

to have a greater number of beneficiaries (118,862 on average), compared with high 

performers (66,180 on average). High performers were more often PPOs (71 percent) than 

were low performers (61 percent). Low performers were less apt to cover residential services 

and provided far fewer SUD IOP, partial hospitalization, or outpatient SUD services than did 

high performers. The mean number of IOP or partial hospitalization services per beneficiary 

ranged from 0.0036 for low performers to 0.0071 for high performers, with the mean number 

of outpatient services ranging from 0.0067 for low performers to 0.0114 for high performers. 

Higher percentages of those with OUDs received MAT for longer than 14 days (47 percent) 

compared with low performers (42 percent). Out-of-pocket inpatient costs were lower for high 

performers ($914.44 vs. $621.15), as was provider reimbursement for inpatient SUD services 

($5790.96 vs. $5521.48). Out-of-pocket costs for MAT medications ($301.91 vs. $302.61) and 

pharmacy reimbursement for MAT medications ($2187.43 vs. 2398.52) also were lower for low 

performers compared with high performers on the initiation measure. Out-of-pocket 

outpatient costs were lower for high performers ($45.16) compared with low performers 

($49.86), whereas outpatient reimbursement showed higher rates for high performers ($147.78 

vs. $215.88).

Compared with the lowest performing plans, plans that were highest performing on initiation 

had more beneficiaries identified with OUDs (0.33 percent vs. 0.26 percent) (Table 17). They 

also had higher percentages of beneficiaries between the ages of 18 and 44 years (54.67 

percent vs. 53.14 percent) and higher percentages of beneficiaries who used the emergency 

department two or more times (24.69 vs. 22.79). Higher-performing plans had fewer 
66

beneficiaries who were female (50.33 vs. 53.48). Market and environmental characteristics 

with little distinction between a low and high performing plan included level of poverty in the 

state, private insurance penetration in the state, and availability of buprenorphine providers in 

the state, although the latter was somewhat higher for high performing plans (8.55 vs. 7.98). 

The high performers did have more beneficiaries in states with high prevalence of opioid 

prescriptions (99.58 vs. 87.33 per 100 population), coverage of all three OUD MAT medications 

(57.47 percent vs. 46.54 percent), and populations with higher percentages of non-Hispanic 

White individuals (71.60 percent vs. 64.95 percent). High performing plans had a lower mean 

number of beneficiaries aged 18 years or older receiving SUD treatment (6.19 vs. 8.23 per 1,000 

population), lower numbers of OTP spaces available for methadone (127.54 vs. 159.72, per 

100,000 population), less money spent on the state SSA per person ($15,300.00 vs. $17,351.80), 

and fewer beneficiaries living in states requiring prescribers or dispensers to access the PDMP 

(61.90 percent vs. 74.00 percent).

TABLE 17. Employer Health Plan Characteristics by Performance on

the NCQA Initiation Measure, Limited to OUDs (N=41)

Health Plan Characteristic

Low 

Performers

N/Mean

Low 

Performers

%

High 

Performers

N/Mean

High 

Performers

%

Initiation measure rate 0.50 --- 0.59 ---

Number of beneficiaries 118862.00 --- 66180.00 ---

Plan type

PPO 25.00 61.00 29.00 70.70

HMO or capitated 9.00 22.00 7.00 17.10

High deductible 7.00 17.10 5.00 12.20

Reimbursement

MAT OOP 301.91 --- 302.61 ---

OP-OOPa49.86 --- 45.16 ---

IP-OOPb914.44 --- 621.15 ---

MAT reimbursement 2187.43 --- 2398.52 ---

OP reimbursementa147.78 --- 215.88 ---

IP reimbursementb5790.96 --- 5521.48 ---

Benefit design

MAT use

None 56.00 --- 50.00 ---

14 days or less 2.00 --- 3.00 ---

>14 days 42.00 --- 47.00 ---

Residential 14.00 34.10 16.00 39.00

IOP/PH services 0.0036 --- 0.0071 ---

OP services 0.0067 --- 0.0114 ---

Beneficiary characteristics

OUD beneficiaries 0.26 --- 0.33 ---

Age 18-44 years 53.14 --- 54.67 ---

Female 53.48 --- 50.33 ---
67

TABLE 17 (continued)

Health Plan Characteristic

Low 

Performers

N/Mean

Low 

Performers

%

High 

Performers

N/Mean

High 

Performers

%

ED use

0 times 57.10 --- 54.12 ---

1 time 20.10 --- 21.19 ---

2 or more times 22.79 --- 24.69 ---

Market characteristics

Opioid prescriptions 87.33 --- 99.58 ---

SUD capacity 8.23 --- 6.19 ---

OTP capacity 159.72 --- 127.54 ---

Buprenorphine prescribers 7.98 --- 8.55 ---

3 MAT 46.54 --- 57.47 ---

Non-Hispanic White 64.95 --- 71.60 ---

Poverty 20.32 --- 20.33 ---

Private insurance 65.24 --- 66.99 ---

PDMP 74.00 --- 61.90 ---

SSA spending 17351.80 --- 15300.00 ---

SOURCE: Truven Health MarketScan CCAE data, 2013-2014.

a. Outpatient services include IOP services and partial hospitalization services in addition to 

other outpatient services.

b. Inpatient services include inpatient and residential services.

Characteristics by performance on the NCQA engagement measure. Health plans also were 

divided into high and low performers on OUD engagement, with mean rates of 0.10 for the low 

performers and 0.21 for the high performers (Table 18). The lowest performing plans for 

engagement also had the highest mean number of beneficiaries. Seventy-six percent of high 

performing plans were PPOs, compared with 56 percent of low performing plans. Residential 

SUD treatment was provided by a higher percentage of high performing plans (42 percent) 

compared with low performers (32 percent). The mean number of IOP or partial hospitalization 

services per beneficiary ranged from 0.0031 for low performers to 0.0075 for high performers, 

with the mean number of outpatient services ranging from 0.0061 for low performers to 0.0120 

for high performers. Compared with low performing plans, high performers were more likely to 

have beneficiaries with OUD who received MAT for more than 14 days (low performing 41 

percent vs. high 48 percent). Differences in reimbursement characteristics were largest for 

median provider reimbursement for inpatient SUD services per user (low performing $5758.57 

vs. high $5553.86), median out-of-pocket costs for inpatient SUD services per user (low 

performing $890.25 vs. $645.35), and median provider reimbursement for outpatient SUD 

services per user (low performing $136.31 vs. high performing $227.34). Median outpatient 

SUD out-of-pocket costs also were higher for high performing plans, but out-of-pocket costs for 

MAT were lower for high performing plans, as was pharmacy reimbursement for MAT.
68

TABLE 18. Employer Health Plan Characteristics by Performance on

the NCQA Engagement Measure, Limited for OUDs (N=41)

Health Plan Characteristic Low Performers

N/Mean

Low 

Performers

%

High 

Performers

N/Mean

High 

Performers

%

Engagement measure 0.10 -- 0.21 --

Number of beneficiaries 115244.00 -- 69797.80 --

Plan type

PPO 23.00 56.10 31.00 75.60

HMO or capitated 10.00 24.40 6.00 14.60

High deductible 8.00 19.50 4.00 9.80

Reimbursement

MAT OOP 304.42 --- 300.10 ---

OP-OOPa46.30 --- 48.71 ---

IP-OOPb890.25 --- 645.35 ---

MAT reimbursement 2300.95 --- 2285.01 ---

OP reimbursementa136.31 --- 227.34 ---

IP reimbursementb5758.57 --- 5553.86 ---

Benefit design

MAT use

None 57.00 --- 49.00 ---

14 days or less 2.00 --- 3.00 ---

>14 days 41.00 --- 48.00 ---

Residential 13.00 31.70 17.00 41.50

IOP/PH services 0.0031 --- 0.0075 ---

OP services 0.0061 --- 0.0120 ---

Beneficiary characteristics

OUD beneficiaries 0.27 --- 0.31 ---

Age 18-44 years 52.29 --- 55.52 ---

Female 53.28 --- 50.53 ---

ED use

0 times 56.87 --- 54.36 ---

1 time 20.22 --- 21.08 ---

2 or more times 22.92 --- 24.57 ---

Market characteristics

Opioid prescriptions 93.29 --- 93.63 ---

SUD capacity 7.88 --- 6.54 ---

OTP capacity 151.28 --- 135.99 ---

Buprenorphine prescribers 7.95 --- 8.58 ---

3 MAT 52.41 --- 51.59 ---

Non-Hispanic White 65.71 --- 70.84 ---

Poverty 20.75 --- 19.90 ---

Private insurance 65.21 --- 67.02 ---

PDMP 69.36 --- 66.54 ---

SSA spending 16110.90 --- 16540.90 ---

SOURCE: Truven Health MarketScan CCAE data, 2013-2014.

a. Outpatient services include IOP services and partial hospitalization services in addition to other 

outpatient services.

b. Inpatient services include inpatient and residential services.
69

Major differences in beneficiary characteristics were not seen between plans at different levels 

of performance, although high performing plans had higher percentages of beneficiaries with 

an identified OUD, had more beneficiaries with OUD using the emergency department two or 

more times, more beneficiaries between the ages of 18-44 years, and fewer beneficiaries who 

were female. Examination of market and environmental characteristics revealed that the 

factors most strongly differentiating low from high performing plans on the engagement 

measure for OUD treatment were that high performing plans were most often in states that 

spent more on the SSA per state population (low performing $16,110.90 vs. high $16,540.90), 

were less likely to be in states where prescribers or dispensers are required to access the PDMP 

(low performing 69.36 percent vs high 66.54 percent), had fewer OTP spaces for methadone 

(low performing 151.28 vs. high 135.99 per 100,000 population), had higher numbers of nonHispanic White individuals in the population (low performing 65.71 percent vs. high 70.84 

percent), and had higher numbers of individuals in the state with private insurance (low 

performing 65.21 percent vs. high 67.02 percent).

Results of multivariate analysis on characteristics influencing initiation and engagement. 

Characteristics significantly associated with higher rates of initiation of OUD treatment among 

employer health plans included providing higher numbers of IOP and partial hospitalization 

services per beneficiary (β = 4.47344, p = 0.0409) and being in a state with above mean 

prevalence of opioid prescriptions per 100 people in the state (β = 0.00228, p = 0.024) (Table 

19). Negative associations also were seen, including higher rates of initiation of OUD treatment 

negatively associated with being in a state where prescribers or dispensers are required to 

access the PDMP under certain circumstances (β = -0.0864, p = 0.0362).

TABLE 19. Multivariate Regression Results Examining the Effect of Health Plan and 

Environmental Characteristics on Employer Health Plan Performance on

the NCQA IET Measures, Limited to OUDs (N=82)

Health Plan Characteristics

Initiation 

Measure

Beta

Initiation 

Measure

p-value

Engagement 

Measure

Beta

Engagement 

Measure

p-value

Number of beneficiaries 2.16E-08 0.7804 -4.4E-08 0.2267

Plan type

PPO Reference Reference Reference Reference

HMO or capitated 0.01573 0.4804 -0.00602 0.5628

High deductible 0.0022 0.922 -0.01354 0.2006

Reimbursement

MAT OOP -1.5E-06 0.98 1.16E-05 0.6735

OP-OOPa0.000373 0.1497 0.000139 0.2494

IP-OOPb-1.1E-05 0.4726 -5E-06 0.4841

MAT reimbursement -7.7E-06 0.6506 1.53E-06 0.8475

OP reimbursementa0.000129 0.1579 8.18E-05 0.057

IP reimbursementb-7.8E-07 0.8422 1.01E-06 0.5826
70

TABLE 19 (continued)

Health Plan Characteristics

Initiation 

Measure

Beta

Initiation 

Measure

p-value

Engagement 

Measure

Beta

Engagement 

Measure

p-value

Benefit design

MAT use

None Reference Reference Reference Reference

14 days or less 0.52499 0.1406 0.22302 0.179

>14 days 0.05631 0.5172 0.03338 0.4114

Residential 0.00705 0.6487 0.00124 0.8637

IOP/PH services 4.47344 0.0409 4.07017 0.0001

OP services -1.0704 0.5242 -0.57529 0.4635

Beneficiary characteristics

OUD beneficiaries 0.34887 0.9667 -10.549 0.0089

Age 18-44 years -0.04029 0.5353 -0.02013 0.507

Female -0.27617 0.13 -0.1958 0.0233

ED use

0 times Reference Reference Reference Reference

1 time 0.12579 0.5519 0.01033 0.9165

2 or more times -0.03954 0.7857 -0.0384 0.572

Market characteristics

Opioid prescriptions 0.00228 0.024 -0.00013 0.7705

SUD capacity 0.00013 0.4067 -9.1E-05 0.2132

OTP capacity 0.00567 0.3107 0.00221 0.3977

Buprenorphine prescribers -0.07678 0.0352 -0.03747 0.028

3 MAT 0.000122 0.948 0.000873 0.3197

Non-Hispanic White -0.00541 0.4227 -0.0006 0.8484

PDMP -0.0864 0.0362 0.00574 0.761

SSA spending -8.2E-07 0.8013 1.35E-06 0.3756

SOURCE: Truven Health MarketScan CCAE data, 2013-2014.

a. Outpatient services include IOP services and partial hospitalization services in addition to 

other outpatient services.

b. Inpatient services include inpatient and residential services.

Initiation measure regression r2: 0.6101.

Engagement measure regression r2: 0.6625.

Higher rates of engagement were associated with providing higher numbers of SUD IOP and 

partial hospitalization services per beneficiary (β = 4.07017, p = 0.0001). Negative associations 

also were seen, such as higher rates of engagement negatively associated with having a higher 

percentage of beneficiaries with an identified OUD (β = -10.549, p = 0.0089) or having a higher 

percentage of beneficiaries who are female (β = -0.1958, p = 0.0233).
71

Qualitative Results 

Plan Characteristics

Six health plans participated in site visit interviews--five Medicaid plans and one commercial 

plan. The plans served geographically diverse populations across the United States. Two plans 

served Western states, two plans covered Midwestern states, one served a Northeastern state, 

and one served a Southeastern state. Health plans described covering diverse populations, 

including urban and rural populations. They varied substantially in the size of their 

membership, ranging from approximately 9,880 to 2.9 million covered lives.

Group interviews with health plans included plan representatives in varying roles--from 

executive leadership to quality improvement strategy teams to clinicians and other staff 

members engaged in beneficiary outreach efforts. The research team interviewed a total of 65 

health plan stakeholders, averaging 11 individuals per plan. To obtain information regarding 

health plan governance, organization, culture, and strategy from key systems leaders, across all 

site visits the researchers interviewed two health plan presidents; eight chief executive officers, 

operating officers, or other individuals in operations leadership positions; four network and 

contracting leaders; two utilization management leaders; two community relations and product 

management leaders and staff members; two chief medical officers; two plan medical 

directors; and six behavioral health medical directors. Quality improvement team members 

interviewed included 12 quality improvement strategy or corporate quality directors and staff 

members. In addition to medical personnel employed in the positions referenced above, to 

obtain information on beneficiary outreach and management and implementation of quality 

improvement strategies, we interviewed clinical stakeholders, including nine health plan 

affiliated providers, four case management team members, and nine care coordinator team 

members.

Interviews with the health plan stakeholders revealed several factors that health plans perceive 

as influencing their ability to initiate and engage beneficiaries in SUD treatment. Results from 

the qualitative analyses are grouped by qualitative research question, and brief deidentified 

summaries of health plan visits are included in Appendix F.

Qualitative Research Question 1: Which types of health plan characteristics and strategies 

are demonstrated by plans with higher performance or greater improvement in IET in SUD 

and OUD treatment?

Health plan governance and organizational structure. Interviewees were asked to describe 

their health plan structure, including leadership organization and governance over behavioral 

health services and SUD IET strategies. Health plan representatives generally described a 

multilevel governance approach, including corporate and local oversight of behavioral health 

care, which included SUD services. National or regional insurance companies operating state 

Medicaid plans described varying mixtures of centralized, corporate oversight for behavioral 

health with local execution of procedures and policies regarding behavioral health utilization 
72

management, care management, and care coordination strategies. National insurance 

companies operating with centralized corporate leadership noted that their approach enabled 

them to streamline decision-making and ensure consistency across their business lines, which 

included other state Medicaid plans, Medicare, and commercial business lines. However, all of 

the national and regional insurance companies stressed that some level of local decisionmaking was critical to implementing behavioral health policies and procedures in ways that 

respond to local population needs.

The extent of health plans’ emphasis on local governance represented a spectrum--from having 

limited local oversight of policy implementation, to equally shared decision-making with the 

corporate office, to local leadership acting with authority over the majority of health plan 

operations and corporate executives viewed as consultants for guidance on specific issues 

(Figure 9). Regional health plans favoring local governance noted that limits on the plan’s 

corporate decision-making were critical to achieving a managed care model that served local 

population needs. Representatives of these plans described the importance of ensuring local 

leadership, with state-specific plan presidents, medical directors, and behavioral health 

directors overseeing locally stationed case management and care coordination teams.

FIGURE 9. Spectrum of Governance Structures and

Factors Affecting Health Plan Organization

Similarly, plans that serve smaller beneficiary populations or that were not nationally 

recognized health insurance brands also favored more local control over decision-making and 

policy implementation efforts. Leadership from locally governed plans described the 

importance of a “feet-on-the-street” approach, which was supported by the interviews with 

care managers and others. As such, representatives from locally governed plans frequently 

described how their organizational structure promoted regular opportunities for 

communication about beneficiary needs or health services access challenges among plan 

presidents, medical directors, and staff members directly involved in beneficiary outreach. 

Health plan representatives described having integrated weekly and monthly rounds with 

clinicians and oversight staff members to discuss beneficiaries with complex needs or 

anecdotally observed trends in initiation and engagement success.
73

The differences in philosophy and approach between the large national plan with more 

centralized leadership and the regional or small plans with much more local control do not 

manifest clearly in the plans’ relative rates of initiation or engagement on IET or on other 

behavioral health measures. The state Medicaid plan operated by the large centralized insurer 

had one of the highest possible rates on initiation but had an engagement rate that was in the 

80th percentile. Plans with pronounced local governance had somewhat similar mixtures or had 

exceptional results on both rates.

Promoting care coordination models and culture. Interviewees from every health plan 

described their plan’s care model and culture as integral to their success in initiating and 

engaging beneficiaries in treatment. Care models consistently were described as focused on 

care coordination. Interviewees emphasized the importance of promoting an understanding of 

patients’ needs for ongoing coordination of physical, mental, behavioral, and substance usespecific services while also managing additional needs such as housing. Having plan-wide care 

coordination models was described as an actionable way to promote health plans’ mission 

statements and values. Interviewees described their health plan culture--and thus care 

coordination models--as reflecting a holistic view of member needs, concerned for underserved 

populations, and focused on collaborative efforts between plan leadership, clinicians, and plan 

members.

Interviewees commented that their respective health plans sustained and reinforced their care 

culture and values by tailoring their processes for staff hiring and provider contracting around 

the plan’s mission statements. Most plans described some process for vetting new care 

coordination staff and clinical providers on the basis of their perceived willingness to approach 

members’ initiation in SUD treatment as a continuous process, rather than an episodic service. 

Health plan representatives also expressed a desire to hire care managers who were willing to 

go beyond phone outreach and follow up with members in the community, including 

conducting house calls, meeting in hospitals or detox facilities, or locating them at communitybased recovery support services. Additionally, plan representatives generally described hiring 

requirements for outreach staff that extended beyond clinical competency and focused on soft 

skills including communication and demonstrating empathy and patience with members.

Interviewees at high performing plans also described a preference for hiring care managers and 

care coordinators who were skilled clinicians with master’s degrees and a few years of 

experience in a variety of care coordination roles. Effective care coordinators and outreach 

workers frequently were described as “trouble shooters” who can identify members’ unmet 

needs. Plan representatives described hiring for a variety of outreach and care coordination 

roles. Behavioral health and medical care managers frequently are used to conduct face-toface visits with members, coordinate care plans, and review entitlements. Plans use clinical 

community specialists and community health workers to conduct community outreach with 

hard-to-reach members including homeless individuals.

All the health plan representatives described the role of hiring case managers, care 

coordinators, and community health workers as promoting beneficiaries’ use of services
74

included within the plan’s benefit array. However, several plans also described these staff 

members as critical to identifying additional community-based recovery supports for members 

beyond the plan’s covered benefits. Health plans expect these staff members to coordinate 

external recovery supports in the hope that members would maintain engagement with 

treatment services longer and become more stable.

Health plan leadership and network contracting staff members described efforts to convey the 

health plan’s mission statement when meeting with new providers. Health plan 

representatives generally expressed a desire to expand their provider network, but many were 

concerned about including providers that do not emulate their health plan values. Provider 

contracting teams described meeting with new providers to reinforce the plans’ commitment to 

continuous engagement with beneficiaries--that repeated successes and failures with SUD 

treatment initiation are part of the recovery process and providers must continuously engage 

patients in communication about the benefits of treatment. The goal is to repeatedly reinforce 

this message so that, if the patient is hearing this on a day when he or she is receptive, the 

provider will be able to initiate a treatment plan with the patient. Plan representatives 

described hiring or contracting with providers and staff members who would promote a culture 

of acceptance among staff and members.

Benefit array. Health plan representatives described significant differences in their benefit 

arrays. Medicaid plan representatives consistently described coverage of outpatient and 

inpatient services, but some stated that they do not reimburse for certain of the intermediate 

services such as partial hospitalization, and only one reimbursed for limited residential care. 

Half of the Medicaid plan representatives also described the need for prior authorization before 

members could engage in several types of SUD treatment services. However, none of the 

Medicaid plans required beneficiaries to pay for any services out-of-pocket. The representative 

of the commercial plan interviewed for this study described the plan’s benefit array as an “allyou-can-eat buffet” of services for beneficiaries, free of prior authorization or utilization 

management review. Although the plan covers an expansive continuum of SUD treatment 

services, members are required to meet their plan deductible prior to having all service costs 

reimbursed by the plan. Deductibles vary on the basis of individual plans offered through the 

commercial insurer.

SIGNIFICANT DIFFERENCES

Health plan representatives described significant differences in their benefit 

arrays.

Representatives of only two plans described having implemented universal early intervention 

activities such as SBIRT. One Medicaid plan implemented universal SBIRT to screen for all 

alcohol and other substance misuse for all beneficiaries aged 12 years and older. One Medicaid 

plan representative described providers’ initial hesitation to conduct SBIRT because of 

uncertainty about how to talk about substance use and competing priorities during the visit. 

The plan representative noted that SBIRT adoption into practice ultimately was driven by a 
75

statewide performance measure that put the plan financially at risk for uptake. The 

commercial plan implements a homegrown SBIRT-like model to screen for risk of alcohol use 

disorder but does not conduct screening for illicit substances. With the support of its research 

department, the plan staff developed an alcohol screening form in-house. Initially the 

commercial plan requested that clinicians conduct brief interventions using evidence-based 

motivational interviewing techniques. However, clinicians expressed discomfort with the 

process, and the plan shifted its SBIRT model to require that clinicians provide members with 

harm reduction advice prior to making a referral to a follow-up visit. To aid in this process, the 

commercial plan developed a loose script for clinicians to reference when giving advice. The 

script mirrors the way in which clinicians talk about diabetes care management and being 

above or below target levels. Clinicians inform plan members about guidelines for safe 

drinking, and then the clinician and plan member discuss whether the member’s drinking 

behavior is above or below those guidelines. Harm reduction strategies such as reducing the 

number of daily drinks or binge drinking episodes are discussed with plan members exceeding 

safe drinking guidelines.

All six plans cover some medically monitored and medically managed detox services, although 

representatives from half of the plans described requiring either a prior authorization or some 

other type of access notification when plan members are admitted to these services. One plan 

in a non-expansion state covers only detox services for pregnant women. All plans cover 

outpatient treatment services without prior authorization. However, inpatient services, 

including intensive inpatient and partial hospitalization services, frequently were described as 

requiring prior authorization from health plans. Representatives from plans requiring some 

level of notification for any of these services indicated that the condition was not meant to limit 

or delay access to care but rather was a method of tracking members and identifying 

individuals in need of case management or care coordination services and follow-up.

Medicaid plan representatives described limitations on their ability to reimburse for residential 

treatment services because of state Medicaid policy. Four of the five Medicaid plan interview 

groups said that their state Medicaid agency did not include residential treatment in Medicaid 

benefits for non-pregnant beneficiaries. The representative from one Medicaid plan with a 

residential treatment benefit described being able to approve their members’ residential 

services only in 7-day increments and with a total average length of stay of 30-days. Because of 

the state Medicaid benefit limits on residential services, most plan representatives described 

having their case managers and care coordinators outreach to community-based programs and 

grants to help members identify funding for residential treatment. In contrast, the commercial 

plan representative reported residential services as a covered benefit.

NALTREXONE

Representatives from only 1 Medicaid plan and the commercial plan indicated 

that they include naltrexone in injection form on their formularies. High cost 

was cited as a barrier for inclusion.
76

All health plans provide members with coverage of at least two MAT medication options for 

opioid treatment. All plan representatives reported covering buprenorphine or buprenorphinenaloxone medications as well as methadone. However, multiple plans described a preference 

for referring members to buprenorphine prescribers over methadone clinics because of plans’ 

ability to coordinate member services with plan-affiliated prescribers rather than having to 

develop relationships and share records with external methadone clinics. The representative 

from one Medicaid plan also described a state policy that required beneficiaries to access 

methadone as a carved-out benefit through another state plan that specifically handled 

methadone treatment. Although the state recently had allowed its Medicaid managed care 

plans to coordinate benefits for methadone maintenance, the plan representative indicated 

that the plan’s history with the carve-out model still deters the plan from promoting 

methadone. Representatives from only one Medicaid plan and the commercial plan indicated 

that they include naltrexone in injection form on their formularies. Plan representatives 

frequently cited the high cost of injectable naltrexone as a barrier to including it on their 

preferred drug lists.

Most plan representatives noted that they did not require prior authorization for MAT. They 

said that removing prior authorizations was important to ensuring access to necessary SUD 

treatment. However, one described maintaining prior authorization for all types of MAT. 

Although the state Medicaid benefit did not require prior authorization, the plan representative 

noted that it was beneficial to ensuring that the plan was knowledgeable about which 

beneficiaries were receiving these services. The plan also wanted to ensure that all 

beneficiaries initiating MAT also were participating in some other SUD treatment service such 

as one-on-one or group counseling. The plan representatives described their MAT service 

authorization similarly to how other plan representatives expressed a need for prior 

authorization on detoxification services. The approval was not meant to serve as an access 

restraint but to keep the plan informed about which beneficiaries were engaging in SUD 

treatment services and might require additional care coordination.

Naloxone formulations are included on all the interviewed plan drug formularies. None of the 

plan representatives described having specific coprescribing practices in place to direct 

providers to prescribe naloxone to members at risk for overdose. However, most indicated that 

they would be receptive to covering the cost of naloxone so that a beneficiary’s family member 

could carry the overdose reversal medication in case of emergency. Leadership at three of the 

interviewed plans said that this topic had been discussed previously in meetings about 

improving SUD treatment outcomes. Representatives from the commercial plan were more 

familiar with providing naloxone to family members of beneficiaries at risk for overdose. Plan 

leadership described a state law that required plans to make the medication available to family 

members of beneficiaries at the same cost that the plan member would pay. Plan leadership 

was supportive of the legislation and the plan’s ability to promote access to the life-saving 

medication.

Coverage of recovery support services was sparse among Medicaid plans. In some cases, peer 

supports are not a covered state benefit and, in at least one instance, the plan did not use peer 
77

support even though the state covered it. The commercial plan provides members with access 

to peer supports as part of their service buffet offered at all SUD treatment clinics affiliated with 

the plan. Their plan members have access to individual and group counseling as well as to 

educational groups focused on relationship building, anger management, depression, 

mindfulness, and other holistic recovery supports at the plan-affiliated clinics.

Although most Medicaid plans do not operate their own educational and recovery support 

groups, they do rely on outreach workers and case managers to identify community-based 

supports for their beneficiaries. Representatives from all but one Medicaid plan described 

sending outreach staff into the community to cultivate partnerships with external peer 

supports, education, and sober living organizations.

Quality improvement activities. Health plans engage in SUD treatment-related quality 

improvement in a variety of ways (Figure 10). Representatives from nationally branded plans 

and those with greater membership populations report employing large quality improvement 

teams that include statisticians and leadership to continuously monitor data trends in 

diagnostics and service use. Representatives from plans with limited resources or those 

without fully integrated EHRs described focusing on enhancing communication channels 

between beneficiaries and the plan and between case management teams and plan leadership 

to identify emerging needs of their covered lives. Almost all plan representatives also spoke 

about the importance of engaging with their provider population to promote uptake of 

evidence-based practices relevant to imitation and engagement in SUD treatment.

FIGURE 10. Quality Improvement Activities Used by Health Plans
78

Health plans struggle overall to achieve full integration of their electronic medical records. 

However, multiple plan leadership groups reported investing significant resources in developing 

fully integrated physical and behavioral health records. Integrated records were described as a 

cutting-edge way for plans to more deeply understand their membership needs. Integrated 

health records allow health plan quality improvement teams to measure the frequency of acute 

care services or diagnostic risk factors for SUDs in their population. Plan representatives 

generally noted confidence in their ability to identify members with the most severe health 

needs. However, plan interviewees described investing in data analytics to identify members 

with moderate health risks and proactively outreach these individuals with additional supports. 

For example, one plan is conducting a monthly analysis of its pharmacy data to identify any 

members who billed for three or more narcotic prescriptions, dispensed by three or more 

pharmacies, with prescriptions written by three or more prescribers. The plan interviewee said 

that this monthly report generates a surprisingly long list of beneficiaries, including a significant 

portion who do not have any SUD or mental health diagnosis in their medical record. The plan 

then shares their monthly report with its care coordination team to identify next steps for 

member outreach.

Plan interviewees also described using integrated EHRs to track members’ progression from a 

positive identification for substance use risk through treatment initiation and engagement over 

time. The commercial plan integrated a universal alcohol SBIRT screening form into their 

medical record. Any members who screen positive for risky alcohol use are flagged for followup. The plan generates a daily report of all members who are identified as having risky alcohol 

use and monitors those individuals for receipt of treatment referral and completion of followup appointments. A monthly report is generated for each plan-affiliated provider practice to 

identify members with a positive alcohol screen, the date of their positive screen, whether a 

referral was made, whether a follow-up appointment and assessment were scheduled and 

completed, whether the member has since initiated any SUD treatment services, and the name 

of the member’s PCP. The plan implemented provider change leaders in each affiliated practice 

to support their effort. Change leaders are selected by the physicians within the local practice 

group and are responsible for reviewing the monthly reports with all physicians in their group. 

Change leaders are helping this plan bridge its advanced data analytic capabilities with more 

traditional quality improvement focused communication strategies.

All interviewed health plan representatives described open communication within the plan and 

between the plan and its membership as key to achieving improvements in SUD treatment. 

Communication strategies included using secure electronic messaging services to maintain realtime communication with providers concerning high-risk beneficiaries, including those with a 

newly diagnosed SUD. Similar to the intent of daily or monthly reports that identify members in 

need of follow-up services, plans are using secure messaging systems to send providers 

reminders to conduct follow-up calls and send outreach letters. Interviewees also described 

these systems as critical ways for providers to reach out to the plan directly, indicating whether 

the provider thinks that a plan member could benefit from care coordination or outreach 

efforts orchestrated by the plan. Providers can essentially “refer” a plan member for care 
79

coordination services to be provided by their health plan. Health plan care coordinators or 

outreach workers then phone the member to discuss his or her care needs. Outreach teams 

are trained on effective communication techniques to encourage members to engage in 

treatment.

CO-LOCATING SERVICES

Representatives from only 1 Medicaid plan and the commercial plan indicated 

that they include naltrexone in injection form on their formularies. High cost 

was cited as a barrier for inclusion. One plan stated that, prior to co-locating 

its SUD treatment counselors in primary care settings, only approximately 

25% of the members they identified as in need of treatment actually initiated 

services.

Ensuring regular opportunities for open communication between care coordinators, outreach 

workers, case managers, and plan leadership including behavioral health medical directors 

were cited frequently as essential to improving treatment initiation and engagement. Every 

interviewed plan described some form of regularly scheduled in-person or conference call 

meeting for health plan staff members to discuss general treatment initiation challenges or to 

focus on strategies to improve outcomes for individual members with complex needs. As 

previously noted, many interviewees considered these regular meetings a critical way to keep 

plan governance leadership informed of membership needs. Interviewees from multiple plans 

described several occasions in which meetings between case managers and plan leadership 

resulted in the plan providing additional support to meet specific member needs. For example, 

interviewees described using plan funds to cover non-reimbursable costs for transportation or 

authorizing additional hospitalization days for members who otherwise would be discharged 

into unsafe living arrangements. 

Overall, health plan interviewees expressed a substantial interest in maintaining 

communication between physical health and behavioral health providers. Primary care 

provider visits are seen as plans’ first opportunity to identify the unmet behavioral health needs 

of their membership population. 

Several plans described the importance of co-locating primary care and SUD treatment services 

as a way to improve treatment initiation. Interviewees described co-locating behavioral health 

counselors in primary care practices as critical to treatment initiation for patients who 

otherwise would not attend services provided in a behavioral health facility. One plan 

anecdotally described that, prior to co-locating its SUD treatment counselors in primary care 

settings, only approximately 25 percent of the members they identified as in need of treatment 

actually initiated services. Interviewees also use co-location as a strategy to overcome patient 

stigma around attending treatment services. The plan estimates that its SUD follow-up rate is 

now 80 percent. Embedding SUD counselors in primary care practices also was seen as 

improving communication between different specialty providers, which facilitated outreach 

efforts to plan members. If a member has disengaged from SUD treatment but attends a 
80

primary care or other medical appointment, the embedded SUD counselor can do a quick faceto-face visit to motivate that member to re-engage in services. 

Many of the health plan representatives described plans to continue expanding efforts to colocate services as a way to facilitate initiation in SUD treatment. For example, members with 

mental health needs frequently attend group sessions, which gives them little time to attend 

one-on-one or group SUD sessions. Co-locating these sessions in the same facility or 

developing more co-occurring group sessions for mental health and SUD issues would help 

more members initiate treatment for their SUD diagnosis. Plan providers described co-location 

as a critical part of their success in treating patients with SUDs. 

Finally, health plans described provider education efforts as an essential piece of their quality 

improvement strategies. One health plan, however, expressed concern about burdening 

providers who must work with multiple insurers and indicated a disinclination to target 

education or initiatives directly at providers, but this plan did not hesitate to engage in quality 

improvement targeted at beneficiaries. Other plans were conscientious about not wanting to 

inundate providers with too much information but aimed to carefully disseminate information 

about targeted best practices in SUD treatment. Interviewees described developing monthly 

webinars, newsletters, and health plan meetings to promote understanding of evidence-based 

practices with providers. Interviewees described these efforts as a way to motivate providers 

while encouraging their accountability for quality health outcomes in the membership 

population. 

Health plans reported investing significant resources in their quality improvement activities 

including developing new staff positions to support activities, investing in software to develop 

their data analytic capabilities, and establishing secure communications with beneficiaries and 

providers. Representatives from two of the Medicaid plans reported focusing their time and 

financial investments on initiatives that targeted activities related to service and quality 

measures for which they were financially at risk under the state Medicaid plan. These plans are 

motivated to maximize their returns on those metrics. Although many of the Medicaid plans 

are part of value-based purchasing at the state level, at the time of interview the majority of 

plans included in this study were not engaging in value-based payment arrangements with 

providers related to substance use metrics. At least two changes that are anticipated in the 

near future would involve providers in shared savings arrangements. However, all plans 

expressed an interest in closely managing their SUD population in an effort to manage overall 

costs. Generally, plan representatives expressed a concern that poorly managed SUDs would 

result in higher overall costs incurred at the emergency department or other ambulatory care 

service providers.
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Qualitative Research Question 2: What other factors (e.g., patient, setting, provider, state, 

and local market characteristics) do health plans identify as affecting rates of initiation and 

engagement in SUD and OUD treatment?

Health plan interviewees described four key external factors they felt affected health plans’ 

effectiveness at initiating and engaging members in SUD treatment services:

1. Federal and state policies--specifically federal privacy and Medicaid-specific policies—

were identified as major factors affecting health plans’ ability to provide comprehensive 

services to meet membership needs.

2. Stigma around SUD and mental health treatment was cited repeatedly as a major 

barrier to treatment initiatives.

3. Plan member attitudes toward treatment and receiving support from their health plan 

were cited as substantially affecting treatment uptake.

4. All health plan representatives cited a general concern over network adequacy for SUD 

treatment services as both a current concern and a major barrier to future access to 

treatment.

Policy factors. Health plans described federal confidentiality requirements of the 42 Code of 

Federal Regulations (CFR) Part 2 as specifically challenging to coordinating care for members 

admitted to detox and other inpatient facilities. 42 CFR Part 2 was established to restrict the 

disclosure of medical records describing an individual’s diagnosis with an SUD or receipt of SUD 

treatment. The regulation requires individuals to provide consent to share any records 

pertaining to services received for SUD treatment. Several health plan representatives 

described detox facilities’ understanding of the release of information requirements for 42 CFR 

Part 2 as overly burdensome to their ability to outreach to members prior to discharge and not 

reflective of the actual regulation requirements. Two plans addressed the recent amendments 

to the regulation and indicated that the amendments did not effectively address the needs of 

health plans to be able to coordinate care for their members. One interviewee characterized 

the recent amendment to the regulation as having “wasted an opportunity.”

Multiple health plan stakeholders described learning of beneficiary detox admissions only after 

the beneficiary had been discharged from the facility. Case managers expressed frustration 

about being unable to engage in predischarge planning or identify new contact information on 

the plan members prior to their discharge. Case managers at one of the health plans described 

spending a significant amount of time working to improve their relationship with local detox

facilities. The case managers are hoping that their positive relationships with the detox

facilities will encourage facility staff to reach out to them, within the confines of 42 CFR Part 2, 

when their plan beneficiaries are admitted for detox services.
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SHORTAGES OF RESIDENTIAL PLACEMENTS

One barrier to obtaining residential treatment for Medicaid health plan 

members is the prohibition against Medicaid reimbursement in so-called 

IMDs with more than 15 beds. This means that many Medicaid health plans 

do not reimburse for residential services. States, however, are increasingly 

seeking Section 1115 waivers to allow such reimbursement under their state 

Medicaid plans. Some health plans also seek residential placements with 

fewer than 16 beds so that reimbursement can be obtained. Despite these 

efforts, significant shortages of residential beds are reported, sometimes 

resulting in health plan members leaving detoxification and re-entering the 

community prematurely.

Each of the five Medicaid plan representatives interviewed identified policies emanating from 

their state Medicaid agency as factors limiting their ability to initiate and engage members in 

SUD treatment. Most of the Medicaid plans viewed restrictions on the types of services 

included in the state Medicaid benefit array as a substantial barrier. These included consistent 

restrictions on reimbursement for residential care given the federal prohibition on 

reimbursement for IMDs. Only one plan representative described the state service benefit as 

providing the full continuum of SUD treatment services, but with restricted ability to reimburse 

for residential treatment. Health plan representatives expressed a desire to cover additional 

treatment services not reimbursable by the state but ultimately noted that doing so was 

beyond their financial capability. Medicaid plan representatives described operating under a 

tight budget without sufficient funds to provide recovery supports outside of the state benefit. 

State Medicaid policies that allow beneficiaries to frequently switch plans also were identified 

as negatively affecting health plans’ ability to coordinate services. Many of the Medicaid plans 

interviewed had authority from the state to place beneficiaries in pharmacy or prescriber lockin programs. Plan representatives described using these programs when beneficiaries were 

identified as receiving several prescriptions for controlled substances such as opioid analgesics 

from multiple prescribers or pharmacies. A few Medicaid plan representatives described 

placing beneficiaries in lock-in programs to monitor their prescription use while conducting 

outreach and case management efforts, only to have the beneficiary switch to another 

Medicaid plan mid-year. Some health plans reported frequent movement of Medicaid 

beneficiaries across state plans throughout a single enrollment year. One plan noted that the 

state Medicaid agency had further restricted movement between plans to control “plan 

shopping” to evade pharmacy and provider lock-ins.

BATTLING STIGMA

Health plans reported investing time in supporting community education 

about SUDs and the positive impact of treatment as ways to reduce stigma 

both in the community at large and in the minds of individuals who might 

need treatment.
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Stigma. Health plan representatives commented on the ways in which stigma around SUDs and 

treatment hindered their ability to effectively initiate and engage members in treatment 

services. Health plans are cognizant of how community stigma toward SUD issues prevents

individuals from identifying a personal need for care and reaching out for support. One 

interviewee who is actively working to cultivate working relationships between her health plan 

and local community organizations described the isolating effect of stigma. Although families 

experiencing a cancer diagnosis are supported by the community at large, families dealing with 

an SUD are not comforted in the same way. Other interviewees echoed this sentiment and 

described how neighborhood stigma can prevent their plan members from wanting to 

participate in recovery supports that do exist in their community. Health plans reported 

investing time in supporting community education about SUDs and the positive impact of 

treatment as ways to reduce stigma both in the community at large and in the minds of 

individuals who might need treatment. One plan also invested in remodeling its SUD treatment 

clinics to make them blend into the local neighborhood. The clinics do not include any signage 

identifying them as treatment facilities for SUDs or mental health conditions--rather their 

facades and waiting rooms are designed as non-specific medical practices.

Health plan representatives also described investing resources in reducing provider stigma 

around SUDs. Interviewees noted that providers often hesitated to conduct substance use risk 

screenings because they had not received adequate addictions training in medical school and 

were uncertain about how to talk to their patients about such issues. One of the interviewed 

health plans is hoping to improve provider-member conversations about SUD issues by training 

their members in self-advocacy. The plan sponsored an education class for members to learn 

about self-efficacy and communications strategies for addressing difficult topics including 

substance use and unmet care needs.

Health plan representatives also said that, although provider stigma related to treating 

members with an SUD has improved, many providers still were hesitant to take on new 

patients, especially those with Medicaid benefits. Plan representatives described conversations 

with providers expressing concern about Medicaid beneficiaries being disruptive in waiting 

rooms and burglarizing their practices for prescription drugs.

Members’ competing needs and attitudes toward treatment. Interviewees described plan 

members’ competing priorities including housing, child care, and accessing treatment for 

comorbid physical and behavioral health conditions as factors affecting successful initiation or 

continued engagement in substance use treatment services. Beneficiaries who are homeless or 

transient were identified as challenging to engage because they do not have stable addresses or 

phone numbers, which would facilitate outreach efforts. Most of the health plan 

representatives reported employing case managers and outreach workers based in the local 

community as a way to engage with community supports that their members might access.

Health plans also described efforts to provide members with transportation to follow-up 

appointments as a means of ensuring attendance. Health plans reported providing bus passes, 

reimbursing taxi costs, and providing gas cards to help individuals with limited finances 
84

overcome transportation barriers. Despite being able to offer these supports, case managers 

indicated that beneficiaries’ attendance at follow-up appointments still was impeded by 

competing demands. For example, one plan representative explained that although members 

were provided a transportation benefit to get to their appointments, the state restricted 

children from accompanying members in the vehicle with them. Thus, to make their SUD 

appointment, beneficiaries with transportation and child care needs face the challenge of 

securing alternative transportation or a babysitter. Interviewed plan case managers said that 

most beneficiaries in this predicament simply do not attend treatment.

Health plan interviewees acknowledged that many of their beneficiaries with an SUD also have 

co-occurring medical and/or other health conditions that hinder their ability to attend SUD 

appointments or achieve medication adherence. Health plans responded by encouraging their 

care managers and outreach workers to meet members where they are and to prioritize 

member-identified needs. Health plan interviewees noted that implementing this approach 

resulted in the plan becoming aware of a member’s need for SUD treatment, but it did not push 

the member to immediately engage in those services. Health plans focusing on this patientcentered approach noted that it was a strategy for keeping the door open to future SUD 

treatment.

Interviews also revealed that health plans are deeply concerned about being seen as a 

trustworthy resource to their members. Several health plans described member attitudes 

toward SUD treatment and health systems in general as a significant factor affecting their 

decision to initiate treatment. Health plan representatives noted that members often viewed 

the plan as an extension of untrustworthy state or other health care systems that they had 

encountered in the past. As a result, members were reluctant to respond to health plan 

outreach efforts. In response, these health plans are invested in developing positive 

relationships with community-based organizations that their members know. For example, one 

health plan representative described having the plan’s outreach workers frequent community 

centers and treatment facilities that its members attend. Over time, the outreach workers 

became more familiar to both the community organizations and the plan members who 

frequent those centers. Integrating plan outreach workers in the community enabled the plan 

members to begin trusting the outreach workers and the health plan. Plan members now are 

more responsive to outreach efforts and care coordination from the health plan.

Requirements for access beyond network adequacy. All of the health plans described specific 

network adequacy requirements including limits on the mileage and travel time for 

beneficiaries to access treatment providers. Although each of the health plans are meeting 

these requirements set out by the state Medicaid agency and their governance boards, 

interviewees repeatedly described having additional network needs. Interviewees expressed 

concern over the growing need for treatment coinciding with decreases in the number of 

medical doctors specializing in SUD treatment. Health plan representatives focused most 

frequently, however, on how limited access to Drug Addiction Treatment Act of 2000 (DATA 

2000)-waivered buprenorphine prescribers and residential treatment beds serve as barriers to 

meeting the treatment needs of their plan members.
85

NETWORK ADEQUACY ISSUES

Growing need for treatment coincides with:

 Decreases in the number of providers specializing in SUD treatment.

 Limited access to buprenorphine prescribers.

 Providers who do not accept Medicaid beneficiaries.

 Lack of residential beds.

 Low reimbursement rates that limit plans’ abilities to expand network 

adequacy for necessary services.

Health plan representatives described actively working on expanding their MAT provider 

networks. One health plan representative reported having its provider relations team conduct

monthly outreach to assess which buprenorphine prescribers are accepting new patients. 

Representatives from this plan indicated that their efforts have not been successful in 

expanding their network adequacy for MAT. They consistently hear that providers do not have 

openings for their members; however, they are continuing to conduct monthly updates in case 

prescribers expand their practices. Other Medicaid plan representatives echoed this 

experience, noting that they find it hard to identify DATA 2000-waivered physicians willing to 

treat Medicaid beneficiaries. Interviewees said that prescribers would not to take on Medicaid 

beneficiaries because of preconceived notions about treating that population or because they 

were accepting cash only for office visit services.

Interviewees from each of the health plans were quick to identify specific challenges in 

contracting with sufficient buprenorphine prescribers to expand their treatment capacity. The 

amount of time spent on documenting buprenorphine treatment to meet DEA requirements 

was identified as a significant barrier for prescribers. One of the health plans is using grant 

funding to hire a Certified Alcohol and Drug Abuse Counselor to support a few of the local 

health plan-affiliated prescribers in multiple aspects of MAT provision, including meeting DEA 

documentation requirements. The counselor conducts educational consultations with the plan 

members about buprenorphine treatment, obtains informed consent, and schedules 

buprenorphine induction. All patient follow-up appointments take place with the counselor 

and the prescribing physician. Other health plan representatives described a desire to support 

prescribers in this way but reported lacking funds to pay for this support.

Additionally, health plans are concerned about the lack of beds available to their beneficiaries 

needing residential treatment facilities. Interviewees at the plan leadership and member 

outreach levels expressed concern over the lack of residential treatment facilities to which they 

could send their beneficiaries following discharge from detox services. Interviewees felt that, 

without residential treatment available to their members, they were watching them get 

discharged from detox only to relapse in the community without the appropriate level of care 

to support them.

Low reimbursement rates for both MAT and residential treatment were identified as significant 

factors limiting plans’ ability to expand network adequacy for necessary services and ultimately 
86

to ensure access to care for plan beneficiaries. Medicaid plan representatives expressed an 

inability to contract with providers at reimbursement rates beyond the state rate. Medicaid 

plans expressed concern that providers withhold open spots from Medicaid beneficiaries to 

receive greater reimbursement rates from commercial plan members and individuals paying

out-of-pocket. Leadership from the commercial plan expressed similar concern over the low 

rates that Medicaid plans can offer providers. Members of commercial plan leadership said 

that they are reluctant to reimburse residential treatment providers at rates substantially 

higher than those set by the state Medicaid agency. Previously the plan had set a higher 

reimbursement rate for residential providers, but in doing so they priced out the state Medicaid 

plans. Members of commercial plan leadership also reported reducing their reimbursement 

rates to help maintain access for Medicaid beneficiaries.

LOW REIMBURSEMENT

Low reimbursement was identified as a significant factor limiting plans’ ability 

to expand network adequacy for necessary services.

The Medicaid plans do contract on an ad hoc basis with out-of-network providers to fill gaps in 

access. Payment is negotiated, and most of the Medicaid plans pay the same rate as they do 

for in-network providers. One plan paid less to provide an incentive to draw providers into the 

network. One paid more but did not want it widely known. Another plan representative 

indicated that paying more than a small amount above the state-established rate was 

burdensome because they would be required to justify doing so to the state.

Qualitative Research Question 3: What do health plan representatives believe are significant 

barriers and facilitators to initiating and engaging beneficiaries in SUD treatment?

Overall, health plan representatives did not feel that challenges to initiating members in care 

differed from the challenges to continued engagement in care. Plan representatives generally 

noted that any barriers to encouraging members to initiate care were the same barriers that 

made it easy for members to disengage after a few visits. In response, health plan 

representatives described identifying and developing facilitation strategies that applied to 

getting members to both initiate and continuously engage in care.

Key barriers identified by plans relate to community stigma toward SUD and treatment, 

providers’ lack of addiction training and comfort treating individuals with an SUD, plan 

members’ readiness for behavioral change, and service limitations of health plan benefit arrays. 

Because many of these findings already have been summarized in response to qualitative 

research Questions 1 and 2, the following section highlights key barriers and their associated 

facilitators.
87

Barrier: Community stigma toward SUDs and behavioral health treatment prevents members 

from initiating and remaining engaged in treatment.

Facilitator: Health plans are focusing on integrating primary care and substance use treatment.

Health plan representatives described substance use-related stigma as communities’ rejection 

and alienation of individuals with an SUD. Interviewees said that communities do not regularly 

engage in conversations about substance use so it becomes a taboo subject when a community 

member has an identified need for SUD treatment. Interviewees described stigma around 

substance use as one of the most significant barriers to encouraging members to initiate and 

remain engaged in treatment. Health plan representatives identified substance use-related 

stigma as greater and more isolating than stigma around mental health conditions. Although 

interviewees noted that alcohol use disorder was less stigmatized than illicit SUD involving 

heroin or opioid analgesics, they identified overcoming stigma as a challenge to bringing 

beneficiaries into treatment.

Health plan representatives frequently described considering substance use-related stigma

when developing strategies to successfully initiate beneficiaries in treatment. Most commonly, 

they focused efforts on co-locating SUD treatment services with primary care. Health plan 

interviewees identified member concerns about attending SUD-specific treatment facilities. 

Members did not want to be seen entering these facilities or have medical records specifically 

list the name of an SUD treatment facility. Interviewees noted that these concerns were 

particularly troubling for individuals who have not accepted their diagnosis, because they were 

more likely to perceive SUD treatment facilities as places for individuals with more severe 

treatment needs. Co-locating SUD treatment services within primary care and other physical 

health practices encouraged members to attend appointments in a familiar environment 

without the stigma of being identified as a behavioral health patient.

WARM HAND-OFFS

Providers were more comfortable having conversations about substance use 

risk behavior and treatment initiation with members knowing that they could 

perform a warm hand-off with the co-located counselor down the hall.

Specifically, most health plan representatives identified embedding SUD treatment counselors 

within primary care offices as their greatest facilitator to overcoming the beneficiaries’ stigma 

around engaging in treatment. Interviewees said that providers were more comfortable having 

conversations about substance use risk behavior and treatment initiation with members 

knowing that they could perform a warm hand-off with the co-located counselor down the hall. 

Counselors were seen as being able to step in to talk to newly diagnosed members or members 

with risky behavior about the benefit of initiating some type of treatment. Interviewees also 

described how embedding counselors improved trust and communication between physical 

health and SUD treatment providers. Simply having these individuals in the same facility 

promoted regular conversations about integration and care coordination planning to support 

members’ holistic needs. Interviewees described this integration as key to engaging in routine 
88

check-ins with members who are reluctant to initiate treatment or become disengaged over 

time. Primary care providers are able to repeatedly advise at-risk members about treatment 

and invite the counselor into the exam room to talk with members about their specific 

reluctance to initiating treatment. Similarly, co-located substance use counselors can check on 

members who come in for physical health appointments and make a subsequent effort to 

engage them in care.

Health plan interviewees described some initial pushback from providers regarding embedding 

SUD treatment counselors and other integration activities. Some providers told the health plan 

they felt that the behavioral health counselors were monitoring or infringing on their practice. 

Health plans responded by having plan leadership reach out to convince providers of the 

potential benefits of primary and substance use care integration.

Barrier: Providers lack sufficient training in addictions medicine to effectively initiate members 

in treatment.

Facilitator: Health plans are routinely engaging providers in education opportunities to promote 

evidence-based practices with substance use treatment.

Health plan interviewees identified primary care providers’ lack of addictions training as a 

critical barrier to identifying risky substance use behavior in members as well as a barrier to 

encouraging members to initiate and engage in treatment. Interviewees described providers as 

generally reluctant to conduct screening for risky substance use. Interviewees said that 

providers reported not feeling comfortable asking the screening questions or knowing how to 

advise individuals who screened positive. Plan representatives acknowledged that early 

intervention activities were difficult for providers because substance use risk screening and 

motivational interviewing techniques were not adequately covered in medical school training. 

As a result, health plan interviewees described developing a variety of educational 

opportunities directed at enhancing providers’ knowledge of best practices for substance use 

screening and treatment.

Health plans that require providers to conduct universal SBIRT with plan members reported 

developing training modules specific to using the screening tool and to conducting the brief 

intervention component for members with an identified risk. One plan representative reported 

holding provider training sessions on how to conduct motivational interviews with members. 

Providers practiced motivational interviewing techniques in person to develop confidence with 

the early intervention practice. Another plan reported abandoning the traditional motivational 

interviewing component of SBIRT in favor of having providers simply offer advice about 

reducing substance use. After providers reported feeling unsuccessful with the original 

motivational interviewing requirement, local plan leadership provided them with risk reduction 

talking points that mimic how providers counsel diabetic patients about glucose levels. 

Members are advised on the safe range of alcohol consumption and how much they would 

need to reduce consumption to be considered within safe medical guidelines.
89

Health plan representatives also reported developing electronic referral, messaging, and 

reporting tools to facilitate providers’ efforts to initiate and engage beneficiaries in treatment. 

Multiple health plans invested in creating provider portals or other electronic systems to 

promote effortless communication between the provider and the health plan. Such systems 

are enabling providers to refer plan members to care coordination services and follow-up care 

with a single click. When this referral is made, health plans are alerted to the request in realtime and begin conducting outreach with the plan member. Health plan representatives said 

that they were motivated to create these tools to partially remove the burden of treatment 

initiation from primary care providers. Instead, the plan can outreach members directly to 

encourage treatment uptake.

Half of the health plan representatives interviewed also described generating provider reports 

on the number of members with an identified SUD and their follow-up treatment status. 

Interviewees noted that plan staff meet one-on-one with providers to discuss their 

performance and identify next steps for engaging members in treatment. Similarly, health 

plans are developing regularly scheduled meetings with providers to discuss best practices in 

SUD treatment. Plan interviewees described these in-person and webinar meetings as 

opportunities to inform providers about practices that close the gap between SUD diagnosis 

and treatment initiation. Meetings highlight the importance of referring members for care 

coordination and case management. Meetings also highlight best practices regarding MAT and 

ASAM criteria regarding level of care and care transitions. Health plans also are promoting 

materials developed by SAMHSA to augment provider knowledge around evidence-based 

practices in SUD treatment. Two of the health plans also reported partnering with local subject 

matter experts and university researchers to promote providers’ understanding of the local 

populations’ needs and attitudes toward SUD treatment.

Overall, health plan representatives noted that their many efforts to educate providers about 

substance use issues and treatment processes are helping them engage members in treatment. 

Most interviewees described wanting to serve as a support for providers and viewed the health 

plan and providers as part of the same team trying to bring members into care. Health plans 

are promoting this team sentiment by carefully scripting the way that they approach education 

with providers. Interviewees said that they were cognizant of not wanting to come off as telling 

physicians how to operate, but they want providers to see best practices and electronic systems 

as valuable tools for their patients.

Barrier: Members are not ready to abstain from substance use or other related risk behaviors, 

which results in an unwillingness to initiate traditional SUD treatment.

Facilitator: Health plans are promoting harm reduction techniques and “no wrong door” and 

“no wrong time” approaches to engage members in conversations about substance use.

Health plan interviewees identified beneficiaries’ readiness to abstain from substance use as a 

significant factor affecting their ability to initiate or sustain engagement in treatment programs.
90

They described treatment programs and care management as historically focused on an 

abstinence-only approach with sobriety as a key requirement for continued engagement. 

Interviewees generally agreed that promoting abstinence-only treatment environments did not 

facilitate initiating members in treatment. As a result, health plan interviewees reported 

gradually shifting their approach to promoting harm reduction environments as well as 

abstinence programs. Representatives from several plans identified this shift to harm reduction 

as a significant facilitator for both initiating members in treatment and maintaining long-term 

engagement.

WHEN HEALTH PLAN MEMBERS DO NOT FEEL READY FOR TREATMENT

Health plans are more frequently promoting harm reduction techniques and 

“no wrong door” and “no wrong time” approaches to engage members in 

conversations about substance use.

Health plan representatives reported offering a variety of harm reduction initiatives to 

members. One plan began sponsoring group sessions that promote conversations between 

members who are reducing their use but have not fully quit. The plan representative noted 

that these groups have been useful for bringing more people into service who did not 

previously self-identify as needing treatment. The harm reduction groups were described as a 

place for members to begin thinking about what treatment would mean for them and what 

healthful behaviors are helpful to them in achieving their personal goals. Health plan 

representatives also described having care managers and outreach workers identify 

community-based harm reduction programs for members to participate in as a first step to 

reducing risky behavior.

Plans described harm reduction strategies as an extension of their intent to promote patientcentered care coordination and a “no wrong door” approach to SUD treatment. Health plan 

representatives described their no wrong door approach as enabling members to engage in any 

kind of treatment services, whether it be physical or behavioral health-focused, and then 

building a trusting relationship with the member to support initiation and engagement in SUD 

treatment. In developing an ongoing relationship with members, health plan interviewees 

noted that they can engage beneficiaries in treatment as soon as members express an interest. 

Thus, the no wrong door perspective also is facilitating a “no wrong time” approach to getting 

members into SUD treatment.

Discussions around the no wrong door approach focused on asking members about their 

priorities and health goals. Health plan representatives acknowledged that this approach was 

more easily promoted through their own care management and care coordination staff than 

through their contracted providers. The challenge with adopting this approach, according to 

interviewees, is that it requires a culture change from the way SUD treatment is traditionally 

viewed. Health plans are using their staff to promote a patient-centered philosophy rather 

than a program-centric approach.
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Barrier: Health plan benefit arrays do not sufficiently cover the continuum of SUD treatment; 

this limits members’ ability to initiate treatment or continue engaging in services that 

appropriately support their recovery needs.

Facilitator: Health plans are investing in staff that support members’ access to communitybased recovery supports and perform outreach to support treatment initiation and engagement.

One of the most significant themes identified in the health plan interviews is how health plans 

are focused on promoting a care coordination model that is based in mission statements about 

individualized and patient-centered care. This approach enables health plans to stretch beyond 

their stewardship of plan benefits to support beneficiaries with care management and outreach 

and to facilitate engagement in community-based recovery supports.

Plan-employed care managers, care coordinators, community health workers, and other 

outreach workers were identified as critical to successfully initiating and engaging members in 

treatment. Health plan interviewees repeatedly acknowledged that their ability to bring 

members into SUD treatment was contingent on their understanding that members have needs 

beyond traditional health services. Health plans are staffing their care management, 

coordination, and outreach teams with clinicians who are experienced and licensed and have a 

master’s degree. Health plans expect these clinicians to conduct face-to-face visits as well as 

telephonic outreach with members wherever they are in the community. When plans learn of 

member admissions to detox or other inpatient facilities, these clinicians are expected to 

conduct immediate outreach with the member. Clinicians in these roles described reaching out 

to members to participate in discharge planning and care transitions and to coordinate 

community-based treatment postdischarge. Interviewees reported sharing their care plans 

with members’ providers to facilitate ongoing treatment efforts and to integrate members’ 

physical and behavioral health care.

Interviewees also reported a consistent expectation from their health plans to understand

members’ holistic needs across substance use, mental health, physical health, and necessities 

such as housing and food. Interviewees consistently described clinicians in these roles as 

“going above and beyond” for health plan members. But health plan representatives 

repeatedly described this level of member outreach as the primary facilitator of getting 

members to the initial SUD treatment visit and ensuring that they continued engaging longterm. Health plan interviewees noted that focusing on their members’ individual needs enables 

their plans to identify key moments when members are receptive to treatment.

COMMUNITY PARTNERSHIPS

Interviewees reported establishing relationships with community-based peer 

support services, educational and employment support agencies, sober 

housing agencies, and other tenancy support organizations.

Additionally, interviewees at all five Medicaid plans identified limits on their covered services as 

restricting access to necessary treatment and recovery supports. As previously discussed, 
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health plan representatives expressed frustration about not always being able to link their 

beneficiaries to partial hospitalization and residential treatment. Some of the Medicaid plans 

also were unable to reimburse for peer support services, which their representatives 

unanimously felt would facilitate their members’ engagement in recovery.

Because of service limits within their own benefits, representatives from all five Medicaid plans 

reported cultivating community partnerships to expand their access to recovery supports across 

systems. Although they reported being unable to reimburse for these services directly, they 

can refer members to the services and help identify grant or donation funding for members 

when necessary. Interviewees reported establishing relationships with community-based peer 

support services, educational and employment support agencies, sober housing agencies, and 

other tenancy support organizations.

Care managers, care coordinators, community health workers, and other plan-employed 

outreach workers are expected to cultivate these community relationships to increase supports 

available to members. Health plan leadership frequently described these non-reimbursable 

services as key to promoting stability in members’ lives and thus promoting their continued 

engagement in SUD treatment. Representatives from half of the plans interviewed reported 

encouraging their staff members to inform leadership about the success of these community 

partnerships. They described efforts to track and report on member progress as a means of 

producing evidence that might support possible inclusion of these services in the plan benefit 

array in the future.

Facilitators and Barriers to Measurement for HEDIS IET

The primary aims of the qualitative interviews and analyses were focused on identifying 

characteristics, strategies, and other factors that affect the ability of successful health plans to 

initiate and engagement members in care. However, several health plans also wanted to 

discuss ways in which they view the criteria of the HEDIS IET measure as affecting their 

measured success in initiating or engaging members in treatment. The following themes are 

drawn from brief conversations with health plans around the structure or calculation of the 

HEDIS IET measures.

Health plan representatives expressed concern about the timeline by which the IET measure 

requires them to meet the initiation and engagement phases of the measure. The initiation 

phase requires individuals to receive inpatient or outpatient treatment within 14 days of an 

initial SUD diagnosis. Health plans have a total of 30 days from the member’s first visit in which 

to complete two additional treatment visits and achieve engagement. Health plan 

representatives indicated that they often did not receive claims data on their members within 

those time frames, and thus they were unable to ensure that members receiving an initial 

diagnosis completed initial and follow-up visits in time to count toward the measure. Plan 

representatives noted that if they failed to receive timely notice of a member’s initial detox 

admission, they likely would fail both the initiation and engagement phases of the measure.
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Health plans also commented on the measure’s requirement that the initial diagnosis and initial 

outpatient or inpatient visit occur with different providers if they are completed on the same 

day. Representatives from two of the health plans commented that they had previously 

encouraged diagnosing providers to walk members into follow-up appointments with different 

providers in order to meet the initiation phase. One reported having financially incented 

providers to conduct this warm hand-off. Health plans enjoyed the option to count same-day 

appointments toward the measure requirements and expressed concern over the criteria being 

changed to require that all visits occur on different dates.

Finally, one health plan representative noted that the measurement criteria used for 

commercial and Medicaid beneficiaries should differ. Plan representatives described how 

general sociodemographic differences between commercial and Medicaid beneficiaries should 

alter the expectations for treatment initiation and engagement timelines. The health plan 

interviewees specifically highlighted challenges in locating Medicaid beneficiaries who are 

homeless or otherwise hard to reach. Plan interviewees noted that the timeline for meeting 

the initiation and engagement phases of the measure should be extended for Medicaid 

populations.
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SYNTHESIS OF FINDINGS AND STUDY IMPLICATIONS 

The opioid crisis has worsened a pre-existing failure to adequately provide SUD treatment to 

many in the United States who desperately need it. Many people in need of treatment do not 

attempt to access it, and many who try find access difficult or impossible. As shown in the 

section of this report on Health Plan Trends for the IET Measure, evidence for this worsening 

crisis may be found in health plan data from across the country, which show declining rates of 

initiation and engagement in SUD treatment between 2005 and 2014.

To identify factors associated with successful treatment initiation and engagement, including 

health plan strategies that may increase rates of involvement in treatment, this study looked at 

models of care, reimbursement, interventions, and best practices that higher-performing health 

plans use to improve initiation and subsequent engagement in SUD and OUD treatment. We 

also examined market, provider, and beneficiary factors that affect plan performance in that 

area.

Our primary focus was to understand how health plans successfully get beneficiaries into SUD 

treatment and keep them there. For convenience, both in developing quantitative analyses and 

in identifying health plans to approach and interview, study researchers relied on the HEDIS IET 

measure. Our real interest, however, lies not in initiation and engagement as defined by that 

measure, but in initiation and sustained participation in treatment for as long as the individual 

patient may require. The IET measure is a tool that got researchers to the point of being able to 

examine factors that influence initiation and engagement more broadly defined.

Our quantitative analyses linking beneficiary, plan, and market characteristics to commercial 

health plans, as well as subsequent semi-structured interviews with high performing plans, 

elucidated key influences identified in the theoretical model (previously described in Figure 1),

which, in turn, derived from the existing literature reviewed as part of the environmental scan.

Individual Influences on SUD Treatment Participation 

Published literature identifies several individual-level influences on SUD treatment 

participation. These include individual beliefs and attitudes such as stigma, individual 

demographic characteristics that may be associated with higher or lower rates of treatment 

involvement, the nature of a person’s substance use (e.g., injection vs. ingested), the person’s 

past experience of SUD treatment, the presence of co-occurring mental health conditions, and 

level of patient activation. Individual influences most often revealed as affecting initiation and 

engagement in this study include the individual’s sex, competing needs, co-occurring 

conditions, stigma, and treatment readiness. Successful plans have implemented initiatives 

designed to address these variables.
95

Most characteristics that fall within the category of individual influences on initiation and 

engagement could not be analyzed in the quantitative analyses, but multivariate regressions 

did show that plans with more female beneficiaries were less likely to perform well on the 

measure of engagement in SUD treatment and OUD treatment. This finding is consistent with 

results in the existing literature.7,8,9,10 Interviews confirmed that health plans have found it 

harder to engage females than to engage males and indicate that this difference often may 

result from competing needs, including child care and transportation, that interfere with access 

to SUD treatment. A woman also may fear loss of custody if she is pregnant or a mother and 

acknowledges having an SUD and seeks treatment. Approaches that some plans have taken to 

address the problem of competing needs include the provision of child care to facilitate 

treatment for mothers and the establishment of a woman’s center that specifically addresses 

pregnant women’s treatment needs. As addressed in the results, however, efforts to address 

these competing needs that are more commonly experienced by females have met with mixed 

success but have been shown to close the treatment gap, in some cases.

In addition to competing needs such as child care and transportation, health plan interviewees 

identified homelessness and co-occurring mental disorders as factors that compete with 

attention to SUD treatment. Those who are homeless can be difficult to reach, and being 

homeless makes treatment attendance more difficult. Although health plans do not pay for 

housing, care managers and outreach workers can and do work with beneficiaries to assist in 

obtaining housing that can facilitate treatment. Similarly, co-occurring mental illness can 

impede treatment initiation and engagement,156 because mental illness and SUD negatively 

affect each other if both are not addressed. Yet, a person’s ability to attend to both may be 

limited. Health plan efforts to identify and implement initiatives that integrate SUD and mental 

health care services seek to provide improved ease of access for care that addresses cooccurring conditions. These and other potentially competing needs get in the way of treatment 

participation. Increased focus on social determinants of health by health plans requires 

resources that many may not have.

As the literature indicates,12 stigma is a powerful barrier to care, and plans that have reached 

out to educate communities about SUD and the positive effects of treatment are taking steps to 

alleviate stigma. Nearly all of the plan representatives with whom we met mentioned the issue 

of stigma associated with SUD. Individuals may feel stigmatized by attitudes in the community, 

by providers, or even by their own family, which may prevent them from seeking treatment or, 

sometimes, even acknowledging the problem.

COMPETING NEEDS

Women historically have been more difficult to engage in SUD treatment. 

Competing needs such as transportation and child care may play a role. 

Addressing those issues may facilitate increased initiation and engagement 

for women.

Plans have reached out to educate communities about SUD and the positive effects of 

treatment, seeking to alleviate such stigma. This education also may increase patient 
96

activation, which is a contributor to treatment participation.62 Plan representatives also cited 

instances in which plans can provide SUD treatment that is fully integrated into treatment for 

physical health as examples of successfully circumventing fears associated with stigma. 

Patients who do not have to enter a building specifically designated as an SUD treatment facility 

but instead can use the same facilities where they access other medical care are less fearful of 

being identified as in SUD treatment. Co-locating SUD and physical health treatment, however, 

often is in the hands of providers rather than plans. Integrated systems and small plans that 

incorporate providers appear better suited to address the physical manifestations of care that 

may alleviate stigma than do larger plans that contract with a host of providers in various care 

settings and that may have difficulty filling their networks regardless of care coordination or colocation capacity. It seems, however, that efforts to integrate care, co-locate services, and 

provide education all can serve to both help alleviate stigma and address conditions that cooccur with SUD.

The literature indicates that younger people in particular may be more comfortable with a harm 

reduction approach to treatment than with an abstinence-based approach.124 To address the 

fact that many patients may not be ready to abstain from substance use, health plans 

increasingly are shifting their approach to promoting harm reduction environments rather than 

abstinence-driven programs. The need to engage people in treatment, even if the goal is harm 

reduction, is important when the only alternative may be continued use at high rates, resulting 

in overdose and exposure to additional health risks.

Provider Influences on SUD Treatment Participation 

Provider characteristics also were identified as influencing treatment initiation and 

engagement. Many health plan interviewees reported feeling that provider stigma about 

treating patients with an SUD, or Medicaid patients generally, interfered with providers’ ability 

or desire to encourage members to initiate SUD treatment. Related to this provider stigma is 

provider discomfort with the subject matter and lack of expertise. Previous research suggests 

that many PCPs do not feel competent about their ability to treat patients with an SUD. 

Physicians cite a lack of addictions-focused training, personal stigma, and time constraints as 

limiting their ability to screen for SUD or link patients with risky behavior to treatment 

services.13,14,15

Many health plan representatives interviewed in the present study described developing a 

variety of educational opportunities directed at enhancing providers’ knowledge of SUD issues 

in general, as well as evidence-based and other best practices for substance use screening and 

treatment. However, one plan expressed reluctance to target initiatives to providers because 

plan staff members fear overwhelming providers with information on new initiatives, tools, and 

other SUD-related information. This plan seemed to focus its efforts more extensively on 

patients than on providers, whereas the remainder of plans attempted both. Upon reviewing 

the relative rankings of this plan with the others on IET, researchers found initiation in the 85th

percentile and engagement in the 95th percentile, with good performance on other behavioral 
97

health measures as well. This limited information does not allow any conclusion to be drawn 

on the preferability of one approach over the other.

Provider shortages also are a factor that can limit SUD treatment initiation and engagement. 

For example, 53 percent of all counties in the United States lack any waivered buprenorphine 

prescribers.87 These and other shortages were mentioned throughout the interviews as 

impeding access to care. Efforts that plans do make to address provider expertise and attitudes 

logically should alleviate provider shortages to some extent as well. Plans did describe 

outreach and other approaches to induce providers into their networks; however, solving the 

problem of provider shortages clearly is not simple, given absolute provider shortages, 

providers only accepting cash, and other factors impeding adequate coverage of beneficiary 

needs. Shortages of individual providers such as addiction specialists, psychiatrists, and 

buprenorphine prescribers, as well as residential treatment, detox facilities, or OPTs, combine 

to make access to the right level of care at the right time difficult for many plan beneficiaries. 

To some extent, these shortages are associated with the lack of available expertise and 

provider desire to work with patients with an SUD. They also pertain to network adequacy--a 

factor discussed later regarding health plan-related factors influencing initiation and 

engagement. However, addressing workforce shortages and adequacy of reimbursement and 

working to reduce stigma are important to alleviate shortages. Further, finding incentives to 

encourage providers to accept insurance or to deincentivize the demand for cash is worth 

exploring to boost the inventory of available providers for individuals with an SUD.

Market and Environmental Influences on SUD Treatment Participation 

Existing literature indicates that SUD treatment gaps often are found in the South, Southwest, 

or Midwest and that OUD treatment gaps are greatest in the Great Plains and in the 

Southeast.87 As a result, the current study aimed to interview health plans in geographically 

diverse locations including the Northeast, Southeast, Midwest, and West. Geographic and 

policy elements interact within this study because two of the interviewed Medicaid plans 

operate under state policies that have not expanded Medicaid eligibility and benefits in 

response to the Affordable Care Act--with one located in the Southeast and the other in the 

Northern Midwest region. Although both of these non-expansion Medicaid plans were higher 

performers on the IET measures, more limited Medicaid coverage may have positively affected 

initiation and engagement rates by eliminating substantial segments of the population with an 

SUD who might have been covered in other states. Further, because of limitations in the state 

Medicaid plan, one of the plans in a non-expansion state did not reimburse for certain services 

(e.g., IOP and partial hospitalization, peer services) that were routinely covered services for 

plans located in expansion states.

In the qualitative component of this study, health plan interviewees identified two national 

policies as significantly influencing treatment participation. Many interviewees cited the 

regulation at 42 CFR Part 2 as interfering with plans’ abilities to coordinate care, most often 

with detox facilities or specialty substance use inpatient facilities. One plan representative 
98

hypothesized that specialty facilities are more familiar with the regulation and thus more 

hesitant to share information about admission or treatment for SUDs, whereas general 

hospitals may be less aware of 42 CFR Part 2 and more likely to operate under the assumption 

that the standard confidentiality provisions apply to all services.

Interviewees from two different health plans made it clear that they regarded the recent 

amendment to the regulation as having “wasted an opportunity” to expand the ability of health 

plans to coordinate care for their enrollees. To address this issue, some plans impose prior 

authorization or notification requirements that allow them to know in advance that an enrollee 

will be admitted, permitting them to follow up. Others are involved in extensive efforts to work 

closely with detox facilities or hospitals to ensure that there is an ongoing close relationship and 

trust and to facilitate systems that permit notification of enrollee admission that will allow 

timely follow-up. In an era when efforts are being made to get away from prior authorization in 

the treatment of SUD, it appears that it does have a role to play in situations such as this, 

although notification rather than authorization may be a subtle difference with fewer 

reimbursement repercussions. Rather than being required to engage in these workarounds, 

however, health plans clearly would prefer either that the regulation be amended or that the 

provider community better understand that plans’ ability to know what is happening with their 

beneficiaries is critical to effective care coordination. The plans obviously see themselves as 

responsible for care coordination and perceive the regulation as a substantial barrier impeding 

their ability to carry out that responsibility.

Another federal policy mentioned was the restriction on Medicaid coverage of care in IMDs. 

Only one of the five representatives from Medicaid plans we interviewed discussed trying to 

identify residential facilities with fewer than 16 beds in order to provide their members access 

to Medicaid-reimbursable residential treatment. Representatives from this Medicaid plan and 

the one commercial plan interviewed both expressed frustration over the limited number of 

residential treatment beds available in their communities, regardless of IMD constraints. Under 

the current Section 1115 SUD delivery system waivers, an increasing number of Medicaid plans 

will be able to reimburse for residential treatment.20 However, access may remain limited 

because of a general shortage of residential treatment capacity. Given that bivariate results 

from the quantitative analyses indicated that the commercial plans reimbursing for residential 

treatment had higher rates of treatment initiation, one hopes that the loosening of 

reimbursement might encourage an increase in the number of beds available if payment is an 

option.

Analyses revealed different ways in which state policies and other state characteristics 

influence treatment initiation and engagement. For example, multivariate analyses indicated 

that higher rates of initiation of OUD treatment were associated with being in a state with a 

higher-than-average prevalence of opioid prescriptions in relation to the state’s population. 

This finding is logical, assuming that higher rates of opioid prescribing are associated with 

higher rates of OUD and higher demand for OUD treatment.
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In quantitative analyses, initiation of OUD treatment also was negatively associated with being 

in a state where prescribers or dispensers are required to access the PDMP in certain 

circumstances. This result simply may mean that identifying problems with opioid prescribing 

or identifying doctor or pharmacy shopping does not translate to referral to OUD treatment. 

Interviews with health plan representatives revealed mixed perspectives on the utility of 

PDMPs. Interviewees reported significant variation in PDMP use in states without laws 

requiring PDMP consultation prior to prescribing, dispensing, or both. However, plans generally 

expressed a desire to use data in ways that would allow them to better identify problems of 

misuse and target treatment initiation and engagement efforts toward those identified as 

obtaining inappropriate controlled substance prescriptions. Although health plans can and do 

use their own claims data for information on prescription fills paid by the plan, access to PDMP 

data would allow the plans to know whether beneficiaries were filling excessive or unnecessary 

prescriptions and paying for them with cash, thereby circumventing plan lock-in policies. 

Recent research using PDMP data has revealed that the implementation of pharmacy lock-ins 

may result in increased out-of-pocket payment for prescription opioids,157 supporting plan 

arguments that access to those data would be useful in curtailing opioid misuse.

Interviews with health plans revealed additional circumstances in which state policies may 

impede or facilitate SUD initiation or engagement. For example, state Medicaid agencies limit 

what their associated Medicaid health plans can reimburse for services such as peer support 

and recovery services. Some plans accept this state benefit restriction, whereas others find 

ways to help beneficiaries access peer services in the community. State Medicaid policies that 

allow beneficiaries to frequently switch plans also were identified as impeding plans’ abilities to 

coordinate services and as permitting patient evasion of plans’ pharmacy lock-in policies. One 

state was reported to have imposed additional limitations on the freedom of Medicaid 

beneficiaries to change plans, thereby mitigating some “plan-shopping.” Low Medicaid 

reimbursement rates and, in one case, substantially delayed reimbursement from the state 

agency, also were identified as significant factors limiting plans’ ability to expand network 

adequacy and ensure access to care for beneficiaries. Medicaid plans expressed concern that 

providers withhold open spots from Medicaid beneficiaries so they can receive greater 

reimbursement rates from commercial plan members and individuals paying out-of-pocket. 

States struggle with these factors that stem from state Medicaid policies and, ultimately, 

budgetary considerations that impede the ability of Medicaid plans to engage providers and 

serve their beneficiaries.

State policies that provide for coverage of MAT or that preclude the use of prior authorization 

for MAT or other SUD services can encourage easier access to needed treatments and facilitate 

initiation and engagement in treatment. As noted earlier, however, plan use of prior 

authorizations for notification purposes can facilitate treatment if it has the effect of alerting 

the plan to patient admission to a detox facility in real time, thereby allowing follow-up prior to 

discharge and subsequent initiation or engagement in step-down treatment. Unfortunately, 

use of prior authorization also may have the effect of making prescribing sufficiently more 

difficult if it creates an unnecessary barrier to care.
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Health Plan Influences on SUD Treatment Participation 

Our review of the literature found three overarching types of health plan interventions that 

have been used to improve initiation and engagement in SUD treatment: (1) implementation of 

evidence-based clinical practices; (2) interventions that may better address the needs of special 

populations; and (3) organizational interventions. Our quantitative analyses and analysis of 

health plan interviews provided us with additional insight into these three categories. As 

already mentioned, health plans may focus some of their quality improvement efforts on 

increasing provider knowledge of SUDs and SUD treatment and on accelerating use of 

evidence-based practices, including MAT. Health plan interventions that address the needs of 

special populations may include interventions: (1) in collaboration with schools or with local law 

enforcement or other correctional systems; or (2) that focus on women who are pregnant or 

parenting or on beneficiaries who are homeless. Health plans also must take account of 

variable substance use in their populations. For example, identifying beneficiaries at moderate 

risk of having an SUD may be difficult, and plans increasingly are using pharmaceutical claims 

mining to find individuals, for instance, who are obtaining excessive opioid prescriptions and 

targeting outreach to those individuals, as well as imposing pharmacy or provider lock-ins. This 

drug utilization review approach is supported by CMS20 and is advocated as part of the HFPP. 

The HFPP encourages the use of data, among other things, to identify patients at risk of opioid 

misuse and OUD and to intervene on the basis of those findings.142 Further, although opioid 

use receives the most attention, alcohol remains the drug used most pervasively and, in some 

areas, other drugs such as cocaine or methamphetamine are commonly used, and individual 

health plans must find ways to address related use disorders appropriately.

Both quantitative and qualitative analyses identified organizational-related interventions as

significant factors in increasing treatment uptake. Some of the current study’s reported 

findings echo those identified in the existing literature, but we also gathered considerable new 

information, providing insights into strategies and structures of health plans that are successful 

at initiating and engaging beneficiaries into SUD treatment.

INTERVENTIONS

Our review of the literature found 3 overarching types of health plan 

interventions that have been used to improve initiation and engagement in 

SUD treatment: (1) implementation of evidence-based clinical practices; (2) 

interventions that may better address the needs of special populations; and 

(3) organizational interventions.

Health Plan Structure

Bivariate quantitative analyses showed that plans with the largest numbers of beneficiaries 

tended to have the lowest rates of initiation and engagement for both SUD and OUD, as did 

plans with higher percentages of beneficiaries with an SUD or an OUD. To some extent, this 

result may be explained by observations from the health plan interviews. The health plan 
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representatives we interviewed were from one small local plan, four medium-sized regional 

plans, and one large national plan. All but the small local plan had a multilevel system of 

governance, with both corporate and local oversight of mental health care and SUD services 

and different degrees of local versus enterprise-level oversight of utilization management, care 

management, care coordination, and quality improvement. However, all the regional or 

national insurance companies stressed that some level of local decision-making was critical to 

implementing behavioral health policies and procedures in ways that responded to local 

population needs. These plans relied heavily on local leadership, with state-specific plan 

presidents, medical directors, and behavioral health directors overseeing regionally stationed 

case management and care coordination teams. Interviewees repeatedly endorsed regular 

communication between corporate and local leadership, as well as internal communication at 

the local level, as critical to address beneficiary needs or access challenges. A locally focused 

approach with ample communication may be one of the ways in which the plans selected for 

interviewing differentiate themselves from others that may fare more poorly on initiation and 

engagement, if lack of local governance and local initiatives are more limited among the latter.

Although the national plan interviewees indicated that their plan depended more on corporate 

oversight and noted that their approach enabled them to streamline decision-making and 

ensure consistency across their business lines, the results of their IET rates were not 

distinguishable from those of the other plans interviewed. It may be more telling, however, 

that only one of the six plans interviewed had a clearly more centralized approach, suggesting 

either that smaller plans are simply more willing to submit to interviews or that a localized 

approach is more likely to place a plan in the upper echelons of IET results. Without better 

understanding of the governance of poorly performing plans, conclusions cannot be drawn 

regarding whether a more locally focused approach is preferable.

Reimbursement and Benefit Design

It appears that the provision of more components of the SUD care continuum influence 

initiation and engagement rates. Multivariate quantitative analyses showed that higherperforming health plans for both SUD and OUD initiation and engagement provided more IOP 

or partial hospitalization services than did lower-performing plans. SUD engagement was 

associated with increased outpatient services as well, whereas, in bivariate analyses, provision 

of residential services was linked to higher initiation rates. Representatives from the six plans 

that we interviewed all discussed the importance of reimbursing for the full SUD care 

continuum. Plan interviewees frequently compared the extent of their SUD service benefit with 

their ability to bring members into SUD care services. When more intensive services such as 

partial hospitalization and residential treatment were unavailable, some health plan 

representatives described finding other creative ways to engage members in inpatient,

outpatient and community-based recovery support services. Although the state Medicaid 

agency sets service benefits for five of the interviewed plans, some of their leadership and care 

coordination teams viewed benefit design as having some mutability and capacity for 

augmentation via community partnerships through coordination of a patchwork of available 

services to substitute for unavailable treatment options.
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Quantitative analyses indicated that out-of-pocket costs and provider reimbursement are other 

factors affecting treatment uptake. Our multivariate analyses found that commercial plans 

with higher rates of SUD treatment initiation had higher-than-average median out-of-pocket 

costs for outpatient SUD services per user. Bivariate analyses showed similar associations 

between higher performance on SUD initiation and engagement and higher out-of-pocket 

outpatient costs and outpatient reimbursement. The same was largely true for OUD treatment. 

These results may not necessarily mean that those commercial plans imposed higher co-pays or 

deductibles. Indeed, bivariate analyses showed that high-deductible plans fared more poorly 

on the IET rates. Instead, it may mean that, for those who require SUD services, more services 

are provided and, with each of those services, a co-pay accrues, increasing the overall out-ofpocket cost to the person for multiple aspects of treatment. This interpretation makes sense, 

given that a higher quantity of outpatient services per beneficiary also was associated with 

better initiation and engagement. There is, however, no assurance that the same result would 

be obtained in a Medicaid population, and the high performing Medicaid plans examined in this 

study did not require any out-of-pocket expenditures. Medicaid plans also generally reported 

not requiring members to face out-of-pocket costs for services available only from out-ofnetwork providers. When out-of-network providers were identified as necessary, the health 

plan representatives reported either contracting with the provider to come into network or 

making special one-time arrangements to reimburse for services at no costs to members.

In contrast to outpatient results, bivariate results showed that inpatient out-of-pocket costs 

and reimbursement were lower for commercial plans that did better on SUD and OUD initiation 

and engagement. This suggests that plans that rely more on intensive and more costly 

inpatient services are not successfully taking that next step of initiating beneficiaries into 

treatment and finding ways to keep them in treatment. Thus, rather than reimburse for lesscostly outpatient services, these lower-performing plans may rely more on hospitalization and 

little else.

There were paradoxical results among the bivariate analyses related to costs and 

reimbursement of MAT as part of OUD treatment, all of which potentially provide evidence that 

improved coverage of MAT is associated with improved initiation and engagement in OUD 

treatment. Higher rates of OUD treatment initiation were associated with higher out-of-pocket 

costs and higher pharmacy reimbursement for MAT medications, which may relate either to 

higher co-pays within the commercial plans or to more permissive induction dosing with 

accompanying higher costs. In contrast, higher rates of engagement were associated with 

lower out-of-pocket costs and pharmacy reimbursement for MAT medications, suggesting that, 

for commercial patients, longer-term use of MAT may be more price sensitive. Bivariate 

analyses of duration of MAT treatment found that higher-performing plans on both initiation 

and engagement in OUD treatment more commonly reimbursed longer periods of MAT 

treatment (more than 14 days) than did lower-performing plans. Among the health plans 

interviewed, all covered at least two opioid MAT drug options--all covered buprenorphine or 

buprenorphine-naloxone and methadone. In other words, all of the health plans selected for 
103

interview perceive MAT to be an integral part of treatment and treat it accordingly within their 

reimbursement structure.

Network Adequacy

On the basis of distance and number of providers proximate to beneficiaries, health plans 

impose internal standards and/or must meet state requirements for network adequacy. 

Although the health plan representatives interviewed reported satisfying their requirements, all 

indicated that these requirements are not always sufficient to ensure adequate access. Many 

of these requirements related to the number of addiction specialists, buprenorphine or 

methadone prescribers, and detox and residential facilities.

Health plan representatives interviewed consistently stated that finding buprenorphine 

prescribers for beneficiaries often was difficult. Many areas lacked waivered prescribers and, 

where there were waivered prescribers, many did not accept patients or did not accept 

Medicaid patients, often preferring cash payments. Health plan interviewees described efforts 

to expand their MAT provider networks, and one health plan interviewee reported conducting 

monthly outreach to assess which buprenorphine prescribers are accepting new patients. 

Methadone availability also sometimes was lacking. The small Medicaid plan had worked with 

a methadone provider located elsewhere in the state to open a new OTP in a town near the 

plan’s center of operations, allowing enhanced access for its beneficiaries. Detox facilities and 

residential treatment facilities for placement after detox also often were lacking. Even though 

most plans could not reimburse for residential treatment, if payment was available from other 

sources, treatment settings sometimes were not. When asked about use of telehealth to 

expand capacity, several plans reported not using it for SUD treatment.

These findings suggest both that alternative approaches to assessing network adequacy and 

that alternative approaches to ensuring treatment access deserve further attention from 

researchers and policymakers. If SUD treatment is cost-effective, investing in options for 

treatment access makes sense to further treatment access and to conserve overall resources.

Integration, Care Coordination, and Care Management

All health plans interviewed have taken significant steps toward integrating care, including

physical health, mental health, and SUD treatment. These steps range from conducting patientfocused and provider-focused interventions such as requiring universal mental health and 

substance use screening by physical health providers or co-locating SUD counseling services in 

physical health settings to internal plan-focused efforts that involve team meetings that can 

address multiple aspects of individual beneficiaries’ needs. Interviewees clearly took a holistic 

view of member needs and were focused on collaborative efforts between plan leadership, 

clinicians, and plan members.
104

INTEGRATED CARE

One of the primary tools to facilitate integrated care, as well as improve 

initiation and engagement in SUD treatment, was the use of plan-based care 

coordinators, care managers, and outreach workers.

One of the primary tools used to facilitate integrated care, as well as improved initiation and 

engagement in SUD treatment, was the use of plan-based care coordinators, care managers, 

and outreach workers. Interviewed plans placed an emphasis on maintaining a balance of such 

staff members who relied on phone contact and others who worked with beneficiaries in the 

community, including conducting house calls or meeting them in hospitals or detox facilities. 

Several health plans also promoted cross-system integration by working with schools, law 

enforcement, providers for homeless individuals, or services for pregnant women.

These health plan care management and coordination positions, and the staff efforts to 

augment reimbursed services, integrate care, and pull individuals with an SUD into treatment, 

are clearly critical to allowing the currently high performing plans to do well on the IET 

measure. Increasing mechanisms to pay for care coordination and management, as well as 

cross-system integration, will be important to improve SUD treatment initiation and 

engagement across a broader range of payers beyond these that are currently higherperforming.

Quality Improvement Initiatives

Health plans reported investing significant resources in quality improvement activities, 

expressing a concern that poorly managed SUDs would result in higher overall costs for the plan 

and inadequate care for beneficiaries. Quality improvement efforts have included developing 

new staff positions to support activities, investing in software to develop data analytic 

capabilities including data mining, and facilitating secure communication with beneficiaries and 

providers.

Although plans that are not provider owned did not engage in shared savings with providers, 

two interviewees mentioned plans to begin, possibly as a pilot or as part of a state Medicaid 

ACO initiative. A number of the plans, however, are themselves subject to alternative payment 

models such as value-based payment or pay-for-performance models designed to incentivize 

desired behaviors or outcomes as part of quality improvement. In the case of Medicaid plans, a 

state will establish certain performance measures (e.g., IET or follow-up after hospitalization) as 

metrics to which payment may attach. States may implement shared savings, whereby higher 

performance results in payment to the plan, and/or may tie metrics to payment withholds, 

whereby the health plan is penalized financially should it fail to meet predetermined state 

benchmarks on SUD measures.

Two of the Medicaid plans reported focusing their time and financial investments on initiatives 

that targeted activities related to quality measures for which they were financially at risk under 

the state Medicaid plan. They are very motivated to maximize their returns on those metrics. 
105

Plans described organizing leadership, contracting teams, and member outreach employees to 

develop and engage in extensive, measure-focused innovations that target multiple aspects of 

health plan organization, communication strategies, and relationship building with providers 

and beneficiaries. Health plans also closely attend to the importance of changing their 

approach and being sensitive to state-directed modifications to measures and payment 

arrangements. As states shift their emphasis to new measures or redesign the way in which 

benchmark metrics can be achieved, plans are actively adjusting their approach and identifying 

new ways to meet these expectations.

This raises three issues for policymakers:

1. Health plans that are not doing well on initiation and engagement either may not be 

subject to a pay-for-performance model or may completely lack the resources to 

respond, and policymakers should understand and address either circumstance.

2. The measures that policymakers select to incentivize must be measures that really 

assess something that is very important to encourage because the focus on those 

measures may reduce focus in other important but unincentivized areas.

3. Removal of a good measure from the group to which incentives attach may result in loss 

of focus and declining performance if the initiatives undertaken to improve 

performance on that measure no longer are sustained.

Study Limitations 

Although this expansive mixed-methods study presents and synthesizes valuable quantitative 

and qualitative data, like all studies it has limitations. The rapid change that has taken place in 

recent years in health care generally, and in behavioral health care in particular, means that 

managed care plans identified for potential interviews based on 2014 results on the IET 

measure were somewhat different when staff members were interviewed in 2017. Plan 

personnel, plan structure, and plan initiatives all changed in the intervening 3 years. Thus, the 

positive rates of initiation and engagement in 2014, as well as plan strategies for improving SUD 

treatment participation, may have continued, grown, or decreased. This means that 

information gathered in interviews represents more closely the status in 2017 than that in 

2014.

Another limitation related to the mixed-methods approach involves the fact that the 

quantitative analyses used commercial insurance data, yet the qualitative interviews were 

primarily with Medicaid plans. Obtaining access to representatives of high performing 

commercial plans for interviews was much more difficult than scheduling interviews with 

representatives of Medicaid plans. Although this limitation represents a difference between 

the quantitative and qualitative aspects of the study, it may provide the benefit of balancing 

the information gathered.
106

Finally, some variables used in the quantitative analyses may not have completely captured the 

sort of information that was intended, particularly among the market and environmental 

characteristics variables. For example, the variable Buprenorphine Prescribers, which relies on 

the SAMHSA website listing waivered buprenorphine prescribers,149 captures imperfect 

information about the number of buprenorphine prescribers actually available and taking 

patients. Evidence from our interviews with health plans clearly indicates that many waivered 

prescribers do not accept any patients or accept less than their limit, and that many who do 

accept patients simultaneously do not accept insurance and require payment in cash. The link 

between high performing health plans and this state-level variable also is attenuated by the fact 

that high performance on IET does not include MAT (e.g., buprenorphine) as treatment and 

relies instead on counseling and other non-medication services, which high performing plans in 

areas with few prescribers may actually rely on more heavily to compensate for the inability of 

their enrollees to easily access MAT. Similarly, SSA Spending--which was intended to indicate 

level of state support for SUDs but actually captures only a portion of resources available within 

states--is an imperfect proxy for market or policy realities.
107

CONCLUSION 

Identifying mechanisms to enhance SUD treatment initiation and continued engagement in care 

is a public health priority. Although more than 20.8 million Americans have a diagnosed need 

for SUD treatment, few access or complete appropriate treatment.1,2 As both administrators 

and coordinators of health care benefits, health plans are positioned to play a crucial role in 

mitigating potential access barriers and developing facilitating mechanisms that bring 

beneficiaries into care and keep them there.

This study sought to identify which health plan characteristics--including models of care, 

interventions, and best practices--are associated with achieving high rates of initiation and 

engagement in SUD treatment. We aimed to examine additional market factors--including 

health policies, provider availability, and population characteristics--that affect performance on 

these measures. Sequential, mixed-method analyses yielded core understandings of how 

health plans navigate obstacles and leverage opportunities to bring members into SUD 

treatment and maintain engagement over time.

The following are some ways in which health plans have the potential to address several key 

barriers while leveraging additional facilitators to achieve high rates of initiation and 

engagement in SUD treatment. Many of these reflect initiatives undertaken by the higherperforming plans interviewed; others are options that may address some of the barriers 

identified but not resolved:

 Coordinating assistance and entitlements for members with competing social demands 

including childcare, transportation, and housing that otherwise prevent them from 

attending treatment appointments.

 Integrating service provision and coordinating treatment plans to address members’ 

holistic physical and behavioral health needs in ways that respond to member-identified 

priorities.

 Augmenting provider and outreach staff knowledge of the SUD care continuum and 

recovery process.

 Implementing care models that support routine check-ins with members about their 

readiness for behavior change and include a spectrum of services from harm reduction 

to more intensive treatment levels that can bring more members into care over time.

 Developing provider-focused and community-focused campaigns to combat stigma 

around SUDs and to promote treatment-seeking behaviors, with greater support for 

members contemplating treatment and for those engaging in the recovery process.
108

 Cultivating health plan outreach staff knowledge of and relationships with communitybased recovery support services to provide members with additional services beyond 

the benefit array.

 Engaging with treatment facilities in educational opportunities that alleviate 

misinterpretations of federal privacy regulations such as 42 CFR Part 2 to encourage a 

common legal understanding of information-sharing restrictions that do not 

unnecessarily hinder health plan outreach and care coordination efforts.

 Investing resources in developing capabilities for data analytics and responsive activities 

that accurately respond to the measured needs of members.

 Scheduling routine communication opportunities between health plan leadership, 

quality improvement teams, contracting teams, and SUD-focused and mental healthfocused teams, including outreach workers and case managers.

Ongoing in-depth examinations of barriers and facilitators to treatment uptake are necessary to 

continue to understand effective methods of enhancing access to recovery services and 

supports for the thousands of individuals in need of care. SUD trends change over time. This 

analysis placed a substantial focus on understanding the specific influences that affect 

treatment uptake for individuals with an OUD because of the current opioid epidemic. Future 

research is needed to continue assessing core variables that affect initiation and engagement as 

drug use patterns evolve and new evidence-based practices are implemented. Close 

monitoring of how health plan and market characteristics affect access and the efficacy of 

treatment are crucial to developing processes and models of care that promote and sustain 

long-term recovery.
109

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A-1

APPENDIX A. GLOSSARY AND ACRONYMS 

TABLE A.1. Glossary of Terms and Definitions

Term Definition

Acamprosate A prescription medication used to aid individuals who are alcohol dependent; 

approved by the Federal Drug Administration in July 2004 for post-withdrawal 

maintenance of alcohol abstinence.a

Addiction Severity Index 

(ASI) Alcohol, Drug and 

Legal Composite Scores

A semi-structured clinical interview used to generate a diagnostic understanding of 

individuals’ substance use treatment needs. The assessment measures need in 7

problem areas including medical, employment/support, alcohol, drug, legal, 

family/social, and psychiatric. Composite scores from each problem area represent 

measures of problem severity to generate deeper understanding of treatment 

planning and evaluation.b

Affordable Care Act 

(Patient Protection and 

Affordable Care Act and 

the Health Care and 

Education Reconciliation 

Act of 2010)

The Affordable Care Act collectively refers to the Patient Protection and Affordable 

Care Act and the Health Care and Education Reconciliation Act that were enacted 

in March 2010. These legislations expanded access to health insurance for lowerincome households by establishing subsidies to offset costs of insurance premiums 

for households with incomes between 100%-400% of the federal poverty level. 

The legislations also enabled states to expand Medicaid coverage to adults with 

incomes below 138% of the federal poverty level. Specific to substance use 

treatment, the Affordable Care Act requires group health plans, group health 

insurance, and individual health insurance to provide behavioral health care 

benefits at parity with medical and surgical benefits.c

Alcohol use disorder A pattern of alcohol use that involves problems controlling drinking, being

preoccupied with alcohol, continuing to use alcohol even when it causes problems, 

having to drink more to get the same effect, or having withdrawal symptoms when 

rapidly decreasing or stopping drinking.d

Binge drinking A pattern of consuming excessive amounts of alcohol in a short period of time. 

National guidelines define binge drinking as consuming alcohol in a way that brings 

blood alcohol concentration levels to 0.08g/dL, which is generally translated to 5

drinks for men and 4 drinks for women during a single drinking episode.e

Buprenorphine Buprenorphine is a medication used in the treatment of opioid dependency. 

Chemically, buprenorphine is a partial opioid agonist and kappa agonist. The doseresponse curve observed from buprenorphine use suggests that, although there is 

potential for misuse, overdose would not result in significant respiratory 

depression. Clinical trials have demonstrated significant efficacy for treating opioid 

dependence.f Buprenorphine was approved for clinical use in October 2002 by the 

FDA for its use in MAT.g 

Buprenorphine-Naloxone A combination medication containing both buprenorphine and naloxone that is 

used in the treatment of opioid dependency. This medication was developed 

because of the potential for diversion and misuse of mono-buprenorphine 

formulations. The naloxone part of the compound precipitates withdrawal in 

individuals who misuse the combined medication via injection. Combined, this 

medication decreases the likelihood of diversion and misuse of the combination 

drug product.f

Care coordination The intentional organization of patient care activities between multiple providers, 

including primary and behavioral health care providers, to facilitate service delivery 

in consideration of patients’ needs and treatment goals. Care coordination is 

achieved largely through the managed exchange of information across several 

aspects of care.h
A-2

TABLE A.1. (continued)

Term Definition

Case management Process by which multiple aspects of an individual’s care is managed, including 

through phases of assessment, treatment planning, care coordination, clinical 

monitoring, evaluation, and advocacy with the goal of meeting an individual’s 

unique needs.i

Cognitive behavioral 

therapy

A type of psychotherapy used in the treatment of individuals with SUDs and other 

psychiatric conditions to help them address harmful thought patterns by learning 

and practicing alternative ways of thinking and behaving that regulate distressing 

emotions and harmful behavior.j

Contingency 

management

Giving individuals tangible rewards to reinforce positive behaviors such as 

abstinence or treatment attendance.k

Co-occurring The presence of more than 1 disorder at the same time, which may include cooccurring behavioral health conditions (mental and SUDs) or co-occurring 

behavioral health and physical health conditions.

Disulfiram The first medication, approved by the FDA in 1951, to treat chronic alcohol 

dependence.l

DSM-IV A manual published by the American Psychiatric Association that includes all 

recognized mental disorders; clinicians and psychiatrists use it to diagnose 

psychiatric illnesses.m

DSM-V The 2013 update to the American Psychiatric Association’s DSM-IV manual that 

represents the most current version of this classification and diagnostic tool.n

Engagement in treatment Treatment engagement implies continued SUD treatment through additional visits, 

usually a specified number of encounters occurring within a set time period that 

may vary depending on the definition. The IET measure defines it generally as “the 

percentage of members with a diagnosis of AOD dependence who initiated 

treatment and had 2 or more additional services within 30 days of the initiation 

visit.”o Engagement also may be examined under the rubric of “retention” or 

“completion.”

Enhanced outreach An outreach approach used to engage specific “hard to reach” groups (populations) 

by using complementary and mutually reinforcing community-based interventions. 

Evidence-based practice Treatments that have documented evidence supporting their efficacy. This may 

refer to treatments for SUDs, mental disorders, or physical health conditions.

Harm reduction Harm reduction is a public health strategy that, among other things, is used for 

individuals with SUDs for whom abstinence is not feasible. Harm reduction 

approaches have been effective in reducing morbidity and mortality in those 

populations.p

HEDIS measures A tool used by health plans to measure performance on dimensions of care and 

service.

Heavy drinking Defined for men as 15 drinks or more per week and for women as 8 drinks or more 

per week.q

Illicit drug use The use of illegal drugs and/or the misuse of prescription medications or household 

substances.

Initiation of use The first use of a substance.

Initiation of treatment Treatment initiation generally indicates that a patient has attended at least 1

treatment or assessment session following his or her identification as someone 

who needs treatment for alcohol or drug use disorders or following an admissions 

process. The IET measure defines it generally as “Initiation: the percentage of 

members who initiate treatment through an inpatient AOD admission, outpatient 

visit, IOP encounter, or partial hospitalization within 14 days of diagnosis.”r
A-3

TABLE A.1. (continued)

Term Definition

Initiation and

Engagement of Alcohol 

and other Drug 

Dependence Treatment 

(IET)

IET is a widely used performance measure for which NCQA is the steward. This 

measure contains separate rates for initiation of treatment and engagement in 

treatment. It is, among other things, part of the HEDIS measure set for health 

plans and is endorsed by the National Quality Forum.s,t

Inpatient treatment Inpatient treatment is a type of intensive treatment in which a patient is provided 

24-hour care at a hospital where medically supervised detoxification can be 

incorporated if needed. This treatment may take place in a medical or a psychiatric 

hospital.

Integrated care Care integration and integrated treatment is a model that seeks to integrate 

treatment of physical, mental, and substance use conditions. Integration may 

focus on treatment, systems of care, and/or financing.

Intensive outpatient (IOP) 

treatment

IOP treatment is a type of specialized addiction recovery program that provides 

daily structure and focused treatment activities where a person attends the 

program on a daily basis that accommodates his or her home and work life.

Medical home model The medical home model is a care delivery model whereby patients’ treatment is 

coordinated through their primary care provider to ensure they receive the 

necessary care when and where they need it and in a manner that they can 

understand.

Medication-assisted 

treatment (MAT)

MAT is an evidence-based treatment involving the use of medications with 

counseling and behavioral therapies to treat either alcohol or OUDs. 

Paul Wellstone and Pete 

Domenici Mental Health 

Parity and Addiction 

Equity Act (MHPAEA) of 

2008

MHPAEA is a federal law that prevents group health plans and health insurance 

issuers that provide mental or SUD benefits from imposing less favorable 

limitations on those benefits than on medical/surgical benefits.

Methadone Methadone is a medication used in MAT to help people reduce or quit their use of 

heroin or other opiates such as prescription opioid pain medication.

Naloxone Naloxone is a medication that blocks or reverses the effects of opioids, including 

extreme drowsiness, slowed breathing, or loss of consciousness. It is used to treat 

opioid or narcotic overdoses in emergency situations. It also is used in the 

compound medication buprenorphine-naloxone. Naloxone was approved by the 

FDA to prevent overdose by opioids such as heroin, morphine, and oxycodone.u

Naltrexone Naltrexone is a medication used to treat OUD and alcohol use disorder and is 

available in oral and injectable forms.

Non-medical drug use The taking of prescription drugs, whether obtained by prescription or otherwise, 

other than in the manner, for the reasons, or in the time period prescribed. It also 

includes a person taking a prescription drug that was not prescribed to him or her 

and is taken for the experience or feeling that the drug causes.
A-4

TABLE A.1. (continued)

Term Definition

Opioid use disorder 

(OUD)

A problematic pattern of opioid use leading to clinically significant impairment or 

distress, as manifested by at least 2 of the following criteria, occurring within a 12-

month period:

 Taking opioids in larger amounts or over a longer period than was intended.

 Having a persistent desire or making unsuccessful efforts to cut down or control 

opioid use.

 Spending a great deal of time in activities necessary to obtain the opioid, use the 

opioid, or recover from its effects.

 Having cravings for or a strong desire or urge to use opioids.

 Recurrently using opioids that results in a failure to fulfill major role obligations 

at work, school, or home.

 Continuing to use opioids despite having persistent or recurrent social or 

interpersonal problems caused or exacerbated by the effects of opioids.

 Reducing or giving up important social, occupational, or recreational activities 

because of opioid use.

 Recurrently using opioids in situations in which it is physically hazardous.

 Continuing to use opioids despite knowledge of having a persistent or recurrent 

physical or psychological problem that is likely to have been caused or 

exacerbated by the substance.v

Opioids (heroin, 

prescription painkillers, 

synthetic opioids)

Opioids are a class of drugs that include the illegal drug heroin, synthetic opioids 

such as fentanyl, and pain relievers available legally by prescription, such as 

oxycodone (OxyContin®), hydrocodone (Vicodin®), codeine, morphine, and many 

others.

Out-of-pocket (OOP) Expenses for medical care that are not reimbursed by insurance. OOP costs include 

deductibles, co-insurance, and co-payments for covered services plus all costs for 

services that are not covered.

Outpatient treatment Outpatient treatment, sometimes called ambulatory care, describes medical care 

or treatment that does not require an overnight stay in a hospital or medical 

facility. A visit to a doctor or counselor for assessment or treatment in a nonhospital setting is an example of outpatient treatment.

Overdose An excessive and dangerous amount of a drug taken intentionally or by accident 

that results in negative health consequences or death.

Partial hospitalization

(PH)

Partial hospitalization provides an intense, structured treatment setting for 

individuals who have difficulty maintaining current daily routines or who would 

otherwise require inpatient behavioral health care. It is provided on a daily basis 

with the person being allowed to reside at home and maintain as much family life 

and work responsibility as possible. (Also see IOP treatment.)

Pay for performance 

(P4P)

Initiatives aimed at improving the quality, efficiency, and overall value of health 

care. These arrangements provide financial incentives to hospitals, physicians, and 

other health care providers to carry out such improvements and achieve optimal 

outcomes for patients. Performance typically is assessed using a performance or 

quality measure.

Performance or quality 

measurement

A performance or quality measurement is the regular measurement of outcomes, 

processes, or other indicators that generate reliable data on the effectiveness and 

efficiency of programs or interventions.

Performance-based 

contracting

A results-oriented contracting method that focuses on the performance of the 

contractor to which at least a portion of a contractor's payment may be tied. The 

contracting parties may be groups consisting of health plan and providers, a state 

and a health plan, a state and providers, or other entities.
A-5

TABLE A.1. (continued)

Term Definition

Pharmacotherapy Pharmacotherapy is the treatment of disease and especially mental illness or SUDs 

with drugs.w

Prescription Drug 

Monitoring Program 

(PDMP)

PDMPs are state-run electronic databases used to track the prescribing and 

dispensing of controlled prescription drugs to patients. These programs are 

designed to monitor this information for suspected abuse or diversion (i.e., 

channeling drugs into illegal use), providing critical information regarding a 

patient’s controlled substance prescription history to prescribers, pharmacists, or 

other parties that have been permitted access. 

Prevalence The percentage of a population that is affected with a particular disease or 

condition at a given time.

Recovery support 

services

Recovery support services are non-clinical services provided to people and families 

during all stages of recovery and may include social supports, transportation, 

employment services and training, case management, relapse prevention, housing 

assistance, child care, peer services, life skills, education, and other support 

services.x

Residential treatment Residential treatment, also called residential or inpatient rehabilitation, describes 

either a mental health facility or a drug and/or alcohol or other addiction 

treatment program that is provided to patients who are in residence (living there 

24/7) for a period of time.

Retention Treatment retention is the level of commitment or engagement in treatment as 

indicated by a patient’s behavior such as number of treatment sessions attended, 

completion of prescribed interventions, days of sobriety, or participation in 

recovery activities.

Single State Authority 

(SSA)

A SSA is a single state agency responsible for coordinating alcohol and drug 

prevention and treatment activities for the state.y

Substance abuse Prior to the most recent DSM-V edition, the DSM-IV used the term substance abuse

to describe the overuse of or dependence on a substance such as alcohol or drugs. 

Refer to the glossary entry for substance use disorder for further description.

Substance dependence Dependence is a term that was used in the DSM-IV but not the DSM-V. The DSM-IV 

defined dependence as “a maladaptive pattern of substance use leading to 

clinically significant impairment or distress, as manifested by 3 (or more) of the 

following, occurring within a 12-month period: Tolerance [defined]..., withdrawal 

[defined].... The substance is often taken in larger amounts or over a longer period 

than was intended. There is a persistent desire or unsuccessful efforts to cut down 

or control substance use. A great deal of time is spent in activities necessary to 

obtain the substance, use the substance, or recover from its effects. Important 

social, occupational, or recreational activities are given up or reduced because of 

substance use. The substance use is continued despite knowledge of having a 

persistent or recurrent physical or psychological problem that is likely to have been 

caused or exacerbated by the substance.”z

Substance use disorder 

(SUD)

A SUD is present when the recurring use of alcohol and/or drugs causes clinically 

and functionally significant impairment, such as health problems, disability, and 

failure to meet major responsibilities at work, school, or home. A diagnosis of SUD 

is based on evidence of impaired control, social impairment, risky use, and 

pharmacological criteria.

aa
A-6

TABLE A.1. (continued)

Term Definition

Washington Circle The Washington Circle is a group of national experts in substance use policy, 

research, and performance management who seek to improve the quality and 

effectiveness of prevention and treatment services through the use of 

performance measurement systems. The Washington Circle was convened and 

supported by the Center for Substance Abuse Treatment since 1998 and was joined 

by the National Institute of Drug Abuse in 2006.bb This group was instrumental in 

developing the measure of IET.

42 Code of Federal 

Regulations (CFR) Part 2

42 CFR Part 2 was established to restrict the disclosure of medical records 

describing an individual’s diagnosis with a SUD or receipt of substance use 

treatment. The regulation requires individuals to provide consent to share any 

records pertaining to services received for SUD treatment.

a. Center for Substance Abuse Treatment. Acamprosate: A new medication for alcohol use disorders. 

Substance Abuse Treatment Advisory. 2005; 4(1). 

https://store.samhsa.gov/shin/content/MS974/MS974.pdf. 

b. McLellan AT, Kushner H, Metzger D, et al. The fifth edition of the Addiction Severity Index. J Subst Abuse 

Treat. 1992; 9(3): 199-213. http://www.journalofsubstanceabusetreatment.com/article/0740-

5472(92)90062-S/pdf

c. Beronio K, Po R, Skopec L, Glied S. Affordable Care Act expands mental health and substance use disorder 

benefits and federal parity protections for 62 million Americans. Washington, DC: HHS Office of the 

Assistant Secretary for Planning and Evaluation; 2013. https://aspe.hhs.gov/report/affordable-care-actexpands-mental-health-and-substance-use-disorder-benefits-and-federal-parity-protections-62-millionamericans. 

d. Mayo Clinic Staff. Diseases and conditions: Alcohol use disorder. 2015. 

http://www.mayoclinic.org/diseases-conditions/alcohol-use-disorder/basics/definition/con-20020866. 

e. National Institute on Alcohol Abuse and Alcoholism. Drinking levels defined. 

https://www.niaaa.nih.gov/alcohol-health/overview-alcohol-consumption/moderate-binge-drinking. 

f. Strain EC, Stoller K, Walsh SL, Bigelow GE. Effects of buprenorphine versus buprenorphine/naloxone tablets 

in non-dependent opioid abusers. Psychopharmacology. 2000; 148(4): 374-383.

https://rd.springer.com/article/10.1007/s002130050066

g. Substance Abuse and Mental Health Services Administration. Buprenorphine. Updated May 31, 2016. 

https://www.samhsa.gov/medication-assisted-treatment/treatment/buprenorphine. 

h. McDonald KM, Sundaram V, Bravata DM, et al. Closing the quality gap: A critical analysis of quality 

improvement strategies (Vol 7: Care Coordination). Technical Reviews, No. 9.7. AHRQ Publication No. 

04(07)-0051-7. Rockville, MD: Agency for Healthcare Research and Quality; 2007. 

https://www.ahrq.gov/downloads/pub/evidence/pdf/caregap/caregap.pdf. 

i. Agency for Healthcare Research and Quality. Comparable Effectiveness of Case Management for Adults 

With Medical Illness and Complex Care Needs. Rockville, MD: Agency for Healthcare Research and Quality; 

2011. https://effectivehealthcare.ahrq.gov/topics/case-management/research-protocol/. 

j. American Addiction Centers. Cognitive Behavioral Therapy and Addiction Treatment. 

http://americanaddictioncenters.org/cognitive-behavioral-therapy/. 

k. National Institute on Drug Abuse. Principles of drug addiction treatment: A research-based guide (Third 

Edition). Contingency Management Interventions/Motivational Incentives (Alcohol, Stimulants, Opioids, 

Marijuana, Nicotine). Updated December 2012. https://www.drugabuse.gov/publications/principles-drugaddiction-treatment-research-based-guide-third-edition/evidence-based-approaches-to-drug-addictiontreatment/behavioral-0. 

l. Center for Substance Abuse Treatment. Incorporating alcohol pharmacotherapies into medical practice. 

Treatment improvement protocol (TIP) series 49. HHS Publication No. (SMA) 09-4380. Rockville, MD; 2009.

m. American Psychiatric Association. Diagnostic and statistical manual of mental disorders, Fourth Edition, Text 

Revision. Washington, DC; 2000.
A-7

TABLE A.1. (continued)

n. American Psychiatric Association. Diagnostic and statistical manual of mental disorders, Fifth Edition. 

Washington, DC; 2013.

o. National Committee for Quality Assurance. HEDIS 2015, Volume 2: Technical Specifications for Health Plans. 

Washington, DC; October 2014.

p. Canadian Paediatric Society. Harm reduction: An approach to reducing risky health behaviours in 

adolescents. Paediatr Child Health. 2008; 13(1): 53-56.

q. Centers for Disease Control and Prevention. Alcohol and public health: Frequently asked questions. 

Updated June 8, 2017. https://www.cdc.gov/alcohol/faqs.htm.

r. National Committee for Quality Assurance. HEDIS 2015, Volume 2: Technical Specifications for Health Plans. 

Washington, DC; 2014.

s. National Committee for Quality Assurance. HEDIS® and performance measurement: Measuring 

performance. http://www.ncqa.org/hedis-quality-measurement.

t. National Quality Forum. Measures, Reports and Tools.

http://www.qualityforum.org/Measures_Reports_Tools.aspx.

u. Substance Abuse and Mental Health Services Administration. Naloxone. March 3, 2016. 

https://www.samhsa.gov/medication-assisted-treatment/treatment/naloxone.

v. American Psychiatric Association. Diagnostic and statistical manual of mental disorders. Fifth Edition. 

Washington, DC; 2013.

w. Merriam-Webster Dictionary. Pharmacotherapy. https://www.merriamwebster.com/dictionary/pharmacotherapy. 

x. Kaplan, L. The role of recovery support services in recovery-oriented systems of care. HHS Publication No. 

(SMA) 08-4315. Rockville, MD: Substance Abuse and Mental Health Services Administration; 2008.

http://www.pacdaa.org/SiteCollectionDocuments/SAMHSA%20White%20Paper%20on%20The%20Role%20

of%20Recovery%20Support%20Services.pdf

y. Rieckmann T, Abraham A, Zwick J, Rasplica C, McCarty D. A longitudinal study of state strategies and 

policies to accelerate evidence-based practices in the context of systems transformation. Health Serv Res. 

2015; 50(4): 1125-1145. doi/10.1111/1475-6773.12273/abstract.

z. Clinical Tools, Inc. DSM-IV-TR Criteria for Substance Abuse and Substance Dependence. Updated September 

11, 2017. https://www.buppractice.com/node/1436. 

aa. American Psychiatric Association. Diagnostic and statistical manual of mental disorders, Fifth Edition. 

Washington, DC; 2013.

bb. Washington Circle. Performance Measurement for Care of Substance Use Disorders. 

http://www.washingtoncircle.org/. Accessed September 15, 2017.
A-8

TABLE A.2. Definitions of Acronyms and Abbreviations

Acronym Definition

42 CFR Part 2 42nd Confidentiality Regulations Part 2 titled Confidentiality of Substance 

Use Disorder Patient Records

ACO Accountable Care Organization

AOD Alcohol and Other Drug

AQC Alternative Quality Contract

ASAM American Society of Addiction Medicine

ASPE HHS Office of the Assistant Secretary for Planning and Evaluation

BCBSMA Blue Cross Blue Shield of Massachusetts 

BHC Behavioral Health Clinic

CCAE Truven Health MarketScan® Commercial Claims and Encounters database

CDC HHS Centers for Disease Control and Prevention 

CEO Chief Executive Officer

CFR Code of Federal Regulations

CMO Chief Medical Officer

CMS HHS Centers for Medicare & Medicaid Services

COO Chief Operating Officer

DATA 2000 Drug Addiction Treatment Act of 2000

DEA Drug Enforcement Administration 

DSM-IV Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition

DSM-V Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition

ED Emergency Department

EHR Electronic Health Record

FDA HHS Food and Drug Administration

HEDIS Healthcare Effectiveness Data and Information Set

HFPP Healthcare Fraud Prevention Partnership 

HHS U.S. Department of Health and Human Services

HMO Health Maintenance Organization

IESD Index Episode Start Date

IET Initiation and Engagement of Alcohol and Other Drug Dependence 

Treatment

IMD Institutions for mental diseases

IOP Intensive Outpatient 

IP Inpatient

MAT Medication-Assisted Treatment

MHPAEA Paul Wellstone and Pete Domenici Mental Health Parity and Addiction 

Equity Act of 2008

MIPS Merit-Based Incentive Payment System

MU Meaningful Use

N-SSATS National Survey of Substance Abuse Treatment Services

NCQA National Committee on Quality Assurance

NDH Negative Diagnosis History

NIATx Network for the Improvement of Addiction Treatment

NSDUH National Survey on Drug Use and Health
A-9

TABLE A.2 (continued)

Acronym Definition

OOP Out-of-Pocket

OP Outpatient 

OTP Opioid Treatment Program

OUD Opioid Use Disorder

P4P Pay For Performance

PCP Primary Care Physician

PDMP Prescription Drug Monitoring Program

PH Partial Hospitalization

PPO Preferred Provider Organization

SAMHSA HHS Substance Abuse and Mental Health Services Administration

SBIRT Screening, Brief Intervention and Referral to Treatment 

SSA Single State Authority

STAR-SI Strengthening Treatment Access and Retention--State Initiative

SUD Substance use disorder

VHA Veterans Health Administration
A-10

APPENDIX B. OPIOID, ALCOHOL, AND OTHER 

SUBSTANCE USE DISORDER DIAGNOSES 

TABLE B.1. OUD Diagnoses

Code Definition

304.00 Opioid dependence--unspecified

304.01 Opioid dependence--continuous

304.02 Opioid dependence--episodic

304.70 Opioid/other dependence--unspecified

304.71 Opioid/other dependence--continuous

304.72 Opioid/other dependence--episodic

305.50 Opioid abuse--unspecified

305.51 Opioid abuse--continuous

305.52 Opioid abuse--episodic

SOURCE: International Classification of Diseases, Ninth Revision, Clinical Modification.
A-11

TABLE B.2. Alcohol and Other SUD Diagnoses

Code Definition

291.0 Delirium tremens

291.1 Alcohol amnestic disorder

291.2 Alcohol persistent dementia

291.3 Alcohol psychotic disorder with hallucinations

291.4 Pathologic alcohol intoxication

291.5 Alcohol psychiatric disorder with delusions

291.81 Alcohol withdrawal

291.82 Alcohol induced sleep disorder

291.89 Alcohol mental disorder not elsewhere classified (NEC)

291.9 Alcohol mental disorder not otherwise specified (NOS)

303.00 Acute alcohol intoxication--unspecified

303.01 Acute alcohol intoxication--continuous

303.02 Acute alcohol intoxication--episodic

303.90 Alcohol dependence NEC/NOS--unspecified

303.91 Alcohol dependence NEC/NOS--continuous

303.92 Alcohol dependence NEC/NOS--episodic

304.10 Sedative, hypnotic, or anxiolytic dependence NOS

304.11 Sedative, hypnotic, or anxiolytic dependence--continuous

304.12 Sedative, hypnotic, or anxiolytic dependence--episodic

304.20 Cocaine dependence--unspecified

304.21 Cocaine dependence--continuous

304.22 Cocaine dependence--episodic

304.30 Cannabis dependence--unspecified

304.31 Cannabis dependence--continuous

304.32 Cannabis dependence--episodic

304.40 Amphetamine dependence--continuous

304.41 Amphetamine dependence--episodic

304.42 Amphetamine dependence--unspecified

304.50 Hallucinogen dependence--unspecified

304.51 Hallucinogen dependence--continuous

304.52 Hallucinogen dependence--episodic

304.60 Drug dependence NEC--unspecified

304.61 Drug dependence NEC--continuous

304.62 Drug dependence NEC--episodic

304.80 Combined drug dependence NEC--unspecified

304.81 Combined drug dependence NEC--continuous

304.82 Combined drug dependence NEC--episodic

304.90 Drug dependence NOS--unspecified

304.91 Drug dependence NOS--continuous

304.92 Drug dependence NOS--episodic

305.00 Alcohol abuse--unspecified

305.01 Alcohol abuse--continuous

305.02 Alcohol abuse--episodic
A-12

TABLE B.2 (continued)

Code Definition

305.20 Cannabis abuse--unspecified 

305.21 Cannabis abuse--continuous

305.22 Cannabis abuse--episodic

305.30 Hallucinogen abuse--unspecified

305.31 Hallucinogen abuse--continuous

305.32 Hallucinogen abuse--episodic

305.40 Sedative, hypnotic, or anxiolytic abuse--NOS

305.41 Sedative, hypnotic, or anxiolytic abuse--continuous

305.42 Sedative, hypnotic, or anxiolytic abuse--episodic

305.60 Cocaine abuse--unspecified

305.61 Cocaine abuse--continuous

305.62 Cocaine abuse--episodic

305.70 Amphetamine abuse--unspecified

305.71 Amphetamine abuse--continuous

305.72 Amphetamine abuse--episodic

305.80 Antidepressant abuse--unspecified

305.81 Antidepressant abuse--continuous

305.82 Antidepressant abuse--episodic

305.90 Drug abuse NEC--unspecified

305.91 Drug abuse NEC--continuous

305.92 Drug abuse NEC--episodic

535.30 Alcoholic gastritis without hemorrhage

535.31 Alcoholic gastritis with hemorrhage

571.1 Acute alcoholic hepatitis

SOURCE: International Classification of Diseases, Ninth Revision, Clinical Modification.
A-13

APPENDIX C. ALGORITHM FOR IDENTIFYING MEMBERS 

WITH ALCOHOL OR OTHER SUBSTANCE USE DISORDERS 

TABLE C.1. Algorithm for Identifying Members with Alcohol or Other SUDs

Measure Component Algorithm

Numerator The number of beneficiaries with at least 1 of the following 3 criteria:

 A medical claim (i.e., a non-radiological and a non-laboratory 

claim) with a diagnosis of alcohol or other drug use in any 

position. Please see Appendix B for diagnoses and diagnostic 

categories. 

 A prescription claim for buprenorphine/naloxone; XR-naltrexone; 

naltrexone; acomprosate; or disulfiram.

 A prescription claim for oral sublingual buprenorphine. 

Injectable, transdermal, and oral buccal buprenorphine are not 

included because they are indicated for pain instead of SUDs.

Denominator Beneficiary-years is calculated by summing the months of enrollment 

for all beneficiaries and dividing by 12. 
A-14

APPENDIX D. SITE VISIT DISCUSSION GUIDE 

Overview 

Purpose. This Site Visit Discussion Guide is for use in the research study, Identifying Best 

Practices and Barriers to Engaging People with Substance Use Disorders (SUD) in Treatment. 

This study is being funded by ASPE.

The purpose of this Site Visit Protocol is to establish a semi-structured discussion guide that will 

be used when interviewing health plans about their successes and challenges in improving 

beneficiaries’ ability to initiate and engage in SUD treatment. In addition, the protocol will be 

used to organize background information about the health plan.

How to use. The initial Logistics section of this Site Visit Protocol is a template that will be 

tailored to each of the six site visits conducted. Tailored Site Visit Protocols will include logistics 

specific to the site visit including an agenda for the visit and contact information for the 

interviewees and research team. 

The Discussion Guide included in this resource provides both a quick reference checklist of the 

key topics to be discussed and the discussion guide by topic. The research team anticipates 

that the guide will be modified for each health plan to include specific health plan profile and 

background information. The research team will decide which topics will be covered for each 

meeting arranged during the site visit. The interviewer can use the checklist to ensure that 

major topics have been covered during the site visit. The Discussion Guide will be used to 

provide primary and probing questions for each topic area. Additionally, the team anticipates 

that the guide will be modified using lessons learned or new focal areas discovered as a result 

of conducting the site visits. Any changes to the guide will be discussed with, reviewed, and 

approved by ASPE prior to implementation in subsequent site visits. 

The Health Plan Background section is another template document that will be tailored to each 

of the six site visits conducted using information gathered about the health plan prior to the 

site visit. This section provides useful background information on the health plan and the 

marketplace in which it is operating.

Table D.2 offers a brief eight-step overview of the interviewer and note-taking process that the 

researchers will review prior to each site visit. Finally, Table D.3 is the physical note template 

that the researchers will use to document each interview.
A-15

Logistics 

TABLE D.1. Site Visit Agenda

[Health Plan Name]

Site Visit Agenda

Date and Time Task Location

Day One: MONTH DD, YYYY

HH:HH a.m.–HH:HH p.m. Meet and Greet: NAMES

HH:HH a.m.–HH:HH p.m. Meeting: NAMES

Topics: 

HH:HH a.m.–HH:HH p.m. Tour: NAMES

Topics:

HH:HH a.m.–HH:HH p.m. Lunch

[NAMES]

HH:HH a.m.–HH:HH p.m. Meeting: NAMES

Topics:

HH:HH a.m.–HH:HH p.m. Meeting: NAMES

Topics:

HH:HH a.m.–HH:HH p.m. Day 1 Wrap-Up

Review Day 2 Agenda

[NAMES]

Day Two: MONTH DD, YYYY

HH:HH a.m.–HH:HH p.m. Meet and Greet: NAMES

HH:HH a.m.–HH:HH p.m. Meeting: NAMES

Topics: 

HH:HH a.m.–HH:HH p.m. Tour: NAMES

Topics:

HH:HH a.m.–HH:HH p.m. Lunch

[NAMES]

HH:HH a.m.–HH:HH p.m. Meeting: NAMES

Topics:

HH:HH a.m.–HH:HH p.m. Meeting: NAMES

Topics:

HH:HH a.m.–HH:HH p.m. Day 1 Wrap-Up

Review Day 2 Agenda

[NAMES]
A-16

Logistics 

Contact Information: The following lists include site visit interviewees and interviewers.

Interviewees at Site Visit

 NAME, Chief Executive Officer, ###-###-####, email 

 NAME, Chief Medical Officer, ###-###-####, email

 NAME, Outreach Coordinator, ###-###-####, email

 NAME, Title, ###-###-####, email

 NAME, Title, ###-###-####, email

 NAME, Title, ###-###-####, email

Interviewers Traveling for Site Visit 

 Peggy O’Brien, [phone redacted], marbrien@us.ibm.com 

 Erika Crable, [phone redacted], ecrable@us.ibm.com
A-17

Discussion Guide 

Key Points Checklists 

Purpose. Use these checklists to ensure that all major subtopics are covered during the health 

plan site visit. Phrasing of questions will be based on questions described in the sections that 

follow this checklist; this checklist is simply a topic area reminder tool for the interviewers. Each 

checklist is specified to the interviewee’s role. 

Health Plan Description

1. Management structure

2. Location of SUD services

3. Carve-in or carve-out benefits

4. Relationship between physical health, 

mental health, and SUD benefits

5. Management and oversight of SUD 

benefits 

Benefit Design

1. Coverage of continuum of care

2. Incorporation of ASAM levels of care

3. Case management or care coordination 

for individuals with SUD

4. Contracted provider types 

5. Coverage of MAT

6. Coverage of support services

Reimbursement Procedures and Rates

1. Payment types used by the health plan 

2. Development of reimbursement rates

3. Impact of reimbursement on access 

4. Reimbursement differences for innetwork and out-of-network providers

5. Use of any alternative payment models, 

including incentives

Community and Market Characteristics

1. Provider availability 

2. Regulation of SUD providers

3. SUD billing

4. State and community attitudes toward 

SUD treatment

Network Adequacy

1. Measuring and maintaining network 

adequacy 

2. Managing low service availability

Quality Improvement Methods

1. Quality improvement initiatives

2. Monitoring provider performance 

3. Reporting measures

Facilitators and Barriers to Engagement

1. Facilitators to initiation and 

engagement

2. Barriers to initiation and engagement

Warm-Up Questions

 Discuss goals of this research. Do you have any additional questions about this project 

before we get started?

 How long have you been with this health plan?

 What are the major responsibilities in your current position?
A-18

Discussion Questions: Health Plan Description 

Discussion Goals: To understand the health plan’s organizational design and management 

Key Points That Need to Be Clarified by Discussion’s Close:

 Roles and responsibilities of the health plan’s leadership team

 Management and oversight of SUD benefits

 Organization of SUD benefits in relation to other behavioral health and physical health 

benefits

Key Words: governance, organizational structure, management, decision-making, 

integration

Health Plan Description Discussion Questions

(If already know answer, use questions to confirm)

 How is your organization structured at a high level? 

PROBES:

o Do you have any major partners?

o Do you provide behavioral health benefits or pharmaceutical benefits directly, or 

do you use a behavioral health carve-out or pharmacy benefit manager? 

 If so, who are they?

 How are those benefits coordinated with the rest of the organization?

o What different lines of insurance do you manage (e.g., Medicaid, commercial,) and 

how do the partners and carve-outs differ?

 Is your state (or health plan and/or national plan) involved in any SUD care 

delivery or financing reform changes? If so, how is your health plan involved 

in those changes?

 [If Medicaid] What impact does your state Medicaid authority’s innovation 

initiatives have on your plan’s care delivery or reimbursement practices?

 [If Medicaid] What impact has your state Medicaid authority’s innovation 

initiatives had on quality improvement initiatives? 

 What is your current management structure, particularly as it relates to behavioral 

health or SUD services? 

PROBES:

o Who has primary oversight of SUD services?

 What type of clinical expertise is included?

o Who has primary oversight of pharmaceutical services? Do they differ for oral 

versus injection medications?

o Who are the other key players and key departments?

o Where do case management or care coordination services fit in the structure?
A-19

 How does your health plan approach the relationship among physical health, mental 

health, and SUD benefits?

PROBES:

o Do you have any integration initiatives? If so, please describe? 

 Care management services to aid members in coordinating benefits?

 Office-based MAT (opioid or alcohol) providers?

 Co-location of services?

o Do these differ among plan types?

 How does your health plan approach the development and implementation of new 

SUD strategies? 

PROBES:

o Are initiatives developed at the national or local level?

o Who is responsible for implementing these strategies? 

o How is the process monitored?

 Does your health plan have clinical or member advisory committees or similar 

structures that inform how you approach your SUD benefits? 

 Are you noticing any trends among your beneficiary population with SUD needs?

PROBES:

o Which age groups seem to be more affected than others?

o Other demographic and geographic trends?

o Co-occurring needs? [relate back to the integration question]

 Describe your beneficiary population’s SUD needs.

PROBES:

o Do SUD issues lie more in alcohol, opioid or other chemical dependencies?

o Among opioids, distinguish between prescription misuse or heroin use.
A-20

Discussion Questions: Benefit Design 

Discussion Goals: To understand the health plan’s SUD service benefit design 

Key Points That Need to Be Clarified by Discussion’s Close:

 Coverage throughout the care continuum

 ASAM levels of care

 Case management services

 Contracting with providers

Key Words: provider type, provider qualifications, benefit array, parity ASAM

Benefit Design Discussion Questions

(If already know answer, use questions to confirm)

 Describe your health plan’s SUD treatment benefit array. For each service discussed, 

who is contracted to provide this service?

PROBES:

o What types of detoxification services are covered?

o What types of residential services are covered if any?

o Are IOP services or partial hospital services covered?

o Are outpatient medical and counseling services covered?

 What, if any, are the limits to counselling services? Does your plan require 

prior authorization, utilization review, medical management activities?

 Describe the prior authorization/utilization review process for service 

coverage.

o Do you have other specialized providers? 

 Pain clinics who can manage members with SUDs?

 HIV clinics?

o Which SUD treatment medications do you cover?

 (If plan has members in more than one state) Does it vary by state of 

residence?

 Do you require prior authorization for these medications?

 Describe the prior authorization process for medications.

 (If not mentioned) Describe any precertification requirements for 

specific services.

 Do these medications have dosage limits or limits to how long individuals can 

remain on them?

o What types of additional crises or support services does your health plan provide?

 Crises services?

 Peer counseling? 

 Aftercare services?

 Case management services?

 Relapse prevention?
A-21

 Patient activation, family activation or engagement?

o Do these services differ by health plan type?

 Does your health plan use the ASAM criteria to assess patients and recommend levels 

of care? If yes, please describe how.

 What case management or care coordination services are available to individuals with 

SUDs?

PROBES:

o What services are provided (i.e., mostly utilization review or prior authorization 

versus social service linkage)?

 Describe the utilization review or prior authorization process.

o Are these services provided directly by the health plan or under contract through 

providers?

o Is there any level of integration with physical health?

o How do these services assist with transitions in care? 

 If yes, how? 

 If no, who assists with transitions of care?

 Describe the types of SUD providers that the health plan contracts with? 

PROBES: 

o Specialized providers? 

 How have SUD benefits changed since the implementation of MHPAEA?

 What have been the barriers to providing the SUD services?

PROBES:

o How have you attempted to address them?
A-22

Discussion Questions: Reimbursement Procedures & Rates 

Discussion Goals: To understand how reimbursement procedures for SUD services, care 

coordination, and recovery support services may be influencing SUD treatment initiation and/or 

engagement 

Key Points That Need to Be Clarified by Discussion’s Close:

 Reimbursement rates for SUD services

 Rate setting process and impact on access

 Alternative payment models

Key Words: reimbursement, rate setting, risk, care coordination, cost sharing

Reimbursement & Rate Discussion Questions

(If already know answer, use questions to confirm)

 What is the payment mechanism you use to reimburse different levels of care for 

substance use treatment services?

PROBES: 

o Is it primarily fee for service? 

o Do you use bundled payments? If so, please describe.

o Do you use any incentive payments? If so, please describe.

o Do you use any financial penalties? If so, please describe.

o Do you use other alternative payment models? If so, please describe.

 Does your payment mechanism differ depending on provider types? How so?

PROBES:

o Differences for inpatient versus outpatient providers?

o Differences between psychologists, psychiatrists, PCPs, masters level counselors, 

peer supports, others?

 How does your reimbursement differ for in-network and out-of-network providers?

PROBES:

o Are there differences in the amount that providers get reimbursed or in the 

amount that the plan member has to pay out-of-pocket for services provided by 

non-preferred providers compared with preferred providers? 

o Which services, if any, are most frequently accessed out of network?

 Do you use any financial mechanisms to ensure smooth transitions of care or care 

integration?

PROBES:

o Incentive payments or penalties for providers?
A-23

 Describe the process for rate setting?

PROBES:

o Have your rates changed over time?

o Do you use a negotiated rate?

 Do you think reimbursement rates impact treatment access and continued 

engagement?

 Do you think reimbursement rates affect network adequacy; for example, which 

providers decide to join your network?

 Do you reimburse for naloxone/Narcan®?

PROBES:

o How is that reimbursement structured for naloxone vs. Narcan vs. Evzio®?

o Are rebates available to the plan or the beneficiary?

o Do you reimburse third parties (e.g., family members, others) who purchase 

naloxone when the beneficiary is the end user?
A-24

Discussion Questions: Network Adequacy 

Discussion Goals: To understand how network adequacy for substance use treatment services 

is impacting initiation and/or engagement

Key Points That Need to Be Clarified by Discussion’s Close:

 Measuring and maintaining network adequacy

 Managing inadequate service availability

Key Words: adequacy, availability, geographic distribution, wait times

Network Adequacy Discussion Questions

(If already know answer, use questions to confirm)

 Describe your health plan’s process for measuring and maintaining network 

adequacy? 

PROBES:

o What standards are you currently required to follow as a result of state, federal, or 

accreditation guidelines?

o Do you use time and distance criteria?

o Do you use wait times?

o Are you using provider-to-member ratios?

o Do your requirements change by geography?

 Main challenges to developing network adequacy?

PROBES:

o Geographic challenges?

o Provider availability?

 How does your health plan manage a lack of SUD service availability?

PROBES:

o Is the plan working with providers to develop any new, specialized services?

o How frequently does the plan re-examine reimbursement rates?

o Has the plan undertaken any initiatives to expand SUD treatment services to 

primary care sites?

o Is the plan implementing or considering the use of telehealth or other mobile 

enhancements?

 Describe how your team is using telehealth. For which services?

 When did this start and what percent of your SUD population is utilizing this 

service?

 Are providers required to have any kind of specialized training to receive 

reimbursement for this service?

 What barriers do you think exist to offering telehealth?
A-25

 Do you think provider wait times are affecting members’ treatment initiation or 

continued engagement in care?

PROBES:

o What is the average wait time for the first SUD appointment?

 What is your health plan’s experience with out-of-network providers?

PROBES:

o Are you experiencing any out of state treatment center solicitation of 

beneficiaries?

o Are there limitations on the types of SUD services that beneficiaries can access out 

of network? 

o What costs do beneficiaries face when out-of-network providers are utilized?

o Are there any OUD services that are only available out of network?
A-26

Discussion Questions: Quality Improvement Methods 

Discussion Goals: To understand how the health plan is monitoring provider performance and 

what kinds of improvement initiatives exist to increase substance use treatment initiation 

and/or engagement

Key Points That Need to Be Clarified by Discussion’s Close:

 Quality improvement initiatives

 Process for monitoring provider performance

 Reporting measures

Key Words: provider performance, quality measures, penetration rates, utilization review, 

P4P, data monitoring

Quality Improvement Discussion Questions

(If already know answer, use questions to confirm)

 How are new SUD quality improvement initiatives developed for your health plan?

PROBES:

o Are they developed at the national, regional, or local level?

o Are they implemented at the national, regional, or local level?

o How is the process monitored?

 What types of quality improvement initiatives has your health plan utilized to improve 

SUD services and SUD service engagement? 

PROBES:

o Provider education?

o Transitions in care? Warm hand-offs, case management, care coordination?

o Pharmaceutical data monitoring to identify high-risk members?

o Improving members’ access to MAT?

o P4P or other value-based purchasing?

o Follow-up programs for individuals who drop out of treatment?

o Recovery support services?

 Do you have any initiatives to engage groups of people who have been traditionally 

hard to engage?

 What are some of the main challenges you have encountered with your quality 

improvement efforts?

 How does your health plan monitor performance?

PROBES:

o Do you use performance metrics? What are they?
A-27

o Do you use quality measures? Which ones?

 The IET Measure?

o What member satisfaction or experience of care measures do you use?

o Do you monitor any of the following?

 Penetration rates

 Outcomes of utilization review

 Member outcomes

 Successful or non-successful care transitions

 Any pharmaceutical data monitoring for maintenance of MAT?

 What is your health plan’s measurement reporting process?

PROBES:

o Are you reporting results publicly and/or privately?

o Do you look at measures at a provider level? If so, do you share it with providers?
A-28

Discussion Questions: Community & Market Characteristics 

Discussion Goals: To understand how community and market factors including attitudes 

toward SUDs, provider availability, billing proficiency, and support services are affecting 

treatment initiation and/or engagement 

Key Points That Need to Be Clarified by Discussion’s Close:

 Provider availability in the market area

 SUD billing proficiency

 Attitudes toward SUD treatment

 State support/funding for recovery support services

Key Words: provider availability, billing, stigma, housing, social services, state funding, state 

regulation, community attitudes

Community and Market Discussion Questions

(If already know answer, use questions to confirm)

 Describe the provider availability in the community for SUD services (note for the 

community overall versus the health plan’s specific network). 

PROBES: 

o Residential service providers?

o MAT providers?

o IOP or partial hospital providers?

o SUD specialty service providers?

o Peer support services?

o Housing and social services?

o Community mental health centers, federally qualified health centers?

 In your areas, how much experience do SUD treatment providers have at billing 

services to insurance versus using grant funding? 

 What are the attitudes toward SUDs and SUD treatment by various members of your 

community? 

PROBES:

o Does your community approach SUDs as a chronic condition using a chronic care 

model or as an acute condition using an acute care model?

o What are local attitudes toward MAT versus abstinence treatment? 

o How have these attitudes affected availability of substance use treatment, if at all? 

o What are the attitudes of law enforcement or criminal justice toward SUD 

treatment? 
A-29

 How are SUD providers generally regulated and funded in your state or community?

PROBES:

o Residential services?

o SUD specialty services? 

o MAT services?

 What kinds of recovery support services are provided by the state or community to 

individuals with SUDs?

PROBES:

o Is the state addressing housing and/or social services for this population?

 From a housing first approach?

o How are these services funded?

 Is the state tracking treatment initiation and engagement rates for individuals 

receiving these services?
A-30

Discussion Questions: Facilitators and Barriers to Engagement 

Discussion Goals: To understand what key informants feel are the primary facilitators and 

barriers to initiating and/or engaging in SUD treatment services 

Key Points That Need to Be Clarified by Discussion’s Close:

 Primary facilitators of initiation and engagement

 Primary barriers of initiation and engagement

Key Words: member characteristics, service availability, specialty services, stigma, evidencebased treatments, chronic care model

Facilitators and Barriers Discussion Questions

(If already know answer, use questions to confirm)

 What are the main factors that you see that facilitate engagement in treatment for 

individuals with SUDs? 

PROBES:

o Member characteristics such as sex, age, comorbid conditions, type of substance 

used?

o Geographic characteristics?

o Provider availability?

o Provider attitude and culture?

o Transition in care programs?

o MAT utilization and availability?

o Reimbursement?

o Specialized services such as specialized pain clinics?

 What do you see as the main barriers to treatment engagement in SUD services in 

your health plan or community? 

PROBES:

o Stigma?

o Geography or local culture?

o Provider culture?

o Lack of evidence-based treatments in practice?

o Poor transitions of care?

o Focus on acute care episodes versus chronic care?

o Housing and social services? 

o Logistical barriers (e.g., transportation, child care, translation)?

 What kind of initiatives is your health plan implementing to reduce the barriers 

described above?
A-31

 Are there any barriers not mentioned above that are specific to MAT?

PROBES:

o Administrative issues around MAT?

o Prior authorizations? (If so, please describe that process.)

o Issues working with multiple insurance companies to cover the different services 

required for effective treatment with MAT?

o Adequate access and provider availability? 

 Does your health plan have any initiatives to improve access to MAT?
A-32

Discussion Questions: The Initiation and Engagement of Alcohol and Other Drug 

Dependence Treatment (IET) Measure 

Discussion Goals: To understand what key informants feel are deficits in how the IET measure 

captures initiation and engagement 

Key Points That Need to Be Clarified by Discussion’s Close:

 Primary problems with measurement using the current IET measure

Key Words: MAT, data, coding

The IET Measure Discussion Questions

(If already know answer, use questions to confirm)

 Can you identify any problems with how the IET measure does or does not capture 

initiation and engagement in SUD treatment?

PROBES:

o MAT not included?

o Data access for all forms of treatment (e.g. residential) or all providers?

o Impediments to coding by primary care providers for behavioral health or vice 

versa?

o Other issues?
A-33

Health Plan Profile/Background: NAME OF PLAN

Health Plan Overview

Summary

Performance on NCQA metrics

Provider Network

Marketplace and Environment 

Summary (including location)

Largest Employers

Leading Health Plans

Largest Healthcare Providers

State Demographics Snapshot from State Variables

[Insert tables for demographics]

Health Plan in the News

[Insert news clippings and summaries of recent and noteworthy headlines]
A-34

TABLE D.2. Interviewer/Notetaking Process

1. Review Discussion Guide questions and health plan information, including notes from 

preliminary outreach calls with the health plan and interviewee background prior to the 

interview. 

2. The lead interviewer and notetaker will pre-select key discussion topics based on the 

interviewee’s position. They will designate pre-determined timing for each topic area based on 

interviewee’s position and keep track of time to assure coverage of all key topics.

3. Inform the interviewee that specific respondents will not be revealed to ASPE. No interviewees 

or health plans will be identified by name in any reports or publications. Information gained 

from the interviewee will be aggregated with data from other health plan interviews for any 

reporting.

4. Provide a project overview (e.g., major goals) and an overview of the topics that will be covered 

during the interview.

5. Ask warm-up questions to start the interview and create a comfortable environment with the 

interviewee.

6. Conduct interview.

7. Close interview by asking, “Is there anything else you would like to share?”

8. Review notes at the end of the interview day to fill in any gaps and record impressions and 

other useful observations.
A-35

TABLE D.3. Template for Site Visit Notes

Interview Information

Date and time MM/DD/YYYY, HH:MM a.m./p.m.

Interviewer’s name

Note-taker’s name

Participant Information

Health plan name

Health plan’s location (general region)

Interviewee(s) Name(s) and titles

Participant Types

Executives (i.e., CEO, CMO, COO) [# interviewed]

Managers (i.e., Directors of Quality, Behavioral 

Health, Contracting, Care Management)

[# interviewed]

Affiliated case managers [# interviewed]

Key providers [describe role, # interviewed]

Other stakeholders [describe role, # interviewed]

Topics covered in interview 

[cross out any topics not covered]

 Topic 1

 Topic 2

 Topic 3

 Topic 4

Discussion

[hand written notes section]
A-36

APPENDIX E. LIST OF NODES USED FOR QUALITATIVE CODING 

FIGURE E.1. Coding Tree for Qualitative Coding
A-37

APPENDIX F. DEIDENTIFIED SUMMARIES OF HEALTH PLAN VISITS 

Site Visit Debrief: SITE ID 2010 

The Truven Health research team conducted a site visit with health plan ID 2010 on February 

14, 2017. During the site visit, the research team met with the health plan’s systems leaders, 

quality improvement team members, clinical leaders, and plan-affiliated case managers 

described in Table F.1. 

TABLE F.1. Site Visit Interviewees for Health Plan ID 2010

Type of Interview Interviewees No. of People

Interviewed

Systems leader 

interview

Health plan Medical Director

Executive Director of the SUD treatment clinic that is 

owned by the health plan

COO of the mental health treatment clinic that contracts 

with the health plan

3

Quality 

improvement team 

interview

Health plan Medical Director 

Executive Director of the SUD treatment clinic that is 

owned by the health plan

2

Clinical leader 

interview

CEO and Medical Director of a major primary care clinic 

with shared ownership that contracts with the health 

plan

Medical Director of the community health center

Executive Director and provider from the women’s health 

center that contracts with the health plan

Executive Director of the SUD treatment clinic that is 

owned by the health center

6

Case management 

interview

Case Manager from the integrated primary care clinic that 

has shared ownership with the health plan

Case Manager from the women’s health clinic that 

contracts with the health plan

Community Health Worker employed by health plan

Executive Director of the SUD treatment clinic that is 

owned by the health plan

4

Clinic tour Tour with clinic CEO and Medical Director of the integrated 

primary care clinic that has common ownership with 

health plan

2

A summary of key findings is included below.

Health Plan Description: The site visit was conducted with a Medicaid plan in the West. The 

plan operates under a coordinated care model and is managed by a local group of providers. 

Thus, the health plan primarily serves a smaller regional member population. The plan is 

focused on providing comprehensive, integrated primary and behavioral health care. It is 
A-38

owned by the partners of a local primary care clinic, who also own and operate a SUD 

outpatient clinic, and it is contracted with a local women’s health center. A local mental health 

clinic also is considered a delegated entity of the plan. These close associations between 

physical and behavioral health providers promote integrated care for members of the plan. 

The plan includes several committees that govern the plan actions. A quality and compliance 

committee meets weekly to review member needs and feedback and to discuss any pertinent 

governance issues arising within the plan. A clinical advisory panel includes plan leadership as 

well as leaders from health facilities within the community. The panel meets monthly to review 

changes within the health plan, changes within state Medicaid policy, and community needs. A 

citizen advisory committee also meets to provide the health plan with feedback on member 

needs.

Facilitators of IET: All interview groups described their co-located SUD and mental health 

treatment counselors as a key facilitator to their success with initiating and engaging 

beneficiaries in SUD services. These counselors are located in the commonly owned integrated 

primary care office. When providers are alerted a patient’s risky substance use behavior or 

have a patient requesting SUD treatment, the providers are able to bring a counselor into the 

examination room for an immediate linkage to care. Individuals who do not want to engage in 

SUD services at an SUD clinic (whether because of stigma or other issues) are able to obtain 

office-based opioid treatment including buprenorphine and certain counseling services in the 

primary care office. This option has improved SUD treatment engagement in their beneficiary 

population.

System leaders and clinical providers also cited their universal SBIRT practices as a “distant 

second” to co-location but nonetheless a major facilitator to SUD treatment initiation. They 

described the utility of the SBIRT screening for identifying risky behavior, but highlighted the colocated counselors as the major facilitator of actual initiation.

Interviewees also identified the small and intimate community-setting in which the health plan 

and its affiliated providers are located and the ability to establish trust between patients and 

providers as key to engagement in treatment.

Barriers to IET: Major initiation and engagement barriers include waitlists for residential 

treatment services throughout the region, an inadequate number of inpatient facilities, and few 

DATA 2000-waivered physicians to prescribe buprenorphine. 

Quality Improvement Methods: The plan relies on local governance to design quality 

improvement initiatives. A quality committee consisting of plan leadership regularly reviews 

members’ needs as well as state Medicaid quality performance metric requirements. The 

health plan focuses resources on achieving benchmark improvements for the metrics they are 

financially at risk for by the state Medicaid agency. When the state included a metric for 

universal SBIRT for SUDs, the plan developed their embedded SUD counselor implementation 

strategy in their local primary care clinic. 
A-39

The plan also is actively monitoring state and national trends in SUD treatment and identifying 

way to implement best practices locally for their population. Previous projects have included 

educational campaigns, specialized screenings for pregnant women, and the creation of a 

pregnancy resource specialist position to coordinate care for pregnant women with SUD.

Benefit Design: The health plan reimburses for all benefits included in the state Medicaid 

benefit array. Reimbursable SUD services include medically monitored and medically 

supervised detoxification programs, outpatient and IOP treatment, inpatient treatment, and 

residential treatment. The benefit array also includes MAT medications including methadone 

and buprenorphine, both of which require prior authorization. Beneficiaries also may receive 

naloxone free of charge under the plan benefit. 

The health plan established an in-house quality committee that is able to approve 

reimbursement for additional services. Plan affiliated providers can bring individual beneficiary 

cases before this committee to lobby for a specific service to be covered if the service is outside 

of the typical benefit design. 

Reimbursement: The health plan reimburses most providers under a capitation model. The 

state Medicaid agency sets rates based on population risk factors, age, and certain 

comorbidities. The plan representatives said this capitation model helps to reinforce their 

chronic care model of treatment. The health plan also is required to report on a set of quality 

health metrics determined by the state Medicaid agency. Universal SBIRT for SUDs is included 

in the state’s quality metrics. The state Medicaid agency places a 4.25 percent withhold on the 

health plan’s total capitated budget. The health plan is eligible to earn back the withhold by 

achieving its improvement benchmarks on the quality measures. A subcommittee within the 

health plan is tasked with determining how to use any withhold earnings that the plan receives 

each year. 

The plan refers beneficiaries out-of-network for specialty services and generally reimburses 

those providers at the standard state Medicaid rate. Care managers and community health 

workers are salaried employees of the health plan. 

Network Adequacy: Several of the health plan representatives expressed concerns over 

network adequacy for various SUD treatment services. There is a general shortage of local 

detoxification facilities and available beds in the region’s residential treatment programs. The 

health plan recently decided to support the opening of a local facility that acts as a “sobering 

center” for individuals requiring a safe environment when the detoxification facilities are 

unavailable. The plan also is referring members to IOP services when residential treatment 

beds are unavailable. The plan began using telehealth to reduce the wait time members 

experience for psychiatry appointments. Additionally, the plan is concerned about the 

availability of DATA 2000-waivered prescribers in their local geographic region, so the plan is 

encouraging their affiliated physicians to become waivered. 
A-40

Market and Beneficiary Characteristics: The health plan serves Medicaid beneficiaries in one 

designated region of the state, with its covered population being predominantly White and 

younger adults. Regarding SUDs, the plan has a growing prevalence of prescription opiate and 

heroin addicted members. However, methamphetamine use is still the most prevalent illicit 

drug in the region. The majority of members with an SUD also have a comorbid mental 

disorder. 
A-41

Site Visit Debrief: SITE ID 2006 

The Truven Health research team conducted a site visit with health plan ID 2006 on April 11, 

2017. During the site visit, the research team met with the health plan’s systems leaders, 

quality improvement team members, and clinical leaders described in Table F.2. 

TABLE F.2. Site Visit Interviewees for Health Plan ID 2006

Type of Interview Interviewees No. of People

Interviewed

Systems leader Vice President of Operations and Execution for Corporate 

Behavioral Health

1

Quality 

improvement team 

Director of Quality and Compliance for Corporate 

Behavioral Health

Leader of Behavioral Health Team’s HEDIS Domain Work 

group

2

Clinical leaders National Behavioral Health Medical Director 

South Regional Medical Director

State Behavioral Health Medical Director 

3

A summary of key findings is included below.

Health Plan Description: A site visit was conducted with a Medicaid plan located in a Southern 

state. The plan covers a significant part of the state, including many of the major cities. This 

local plan is part of a larger national health insurer group and thus is managed both locally and 

with substantial oversight from the corporate office. Behavioral health initiatives and decisions 

are initiated at the corporate level to ensure operational and clinical consistency across state 

plans. The local health plan quality teams are responsible for implementing behavioral health 

policies and procedures, ensuring compliance with state regulations, and developing initiatives 

of their own. Leaders of the plan expressed a commitment to having local behavioral health 

and physical health medical directors operate within their community while communicating 

closely with the national corporate office and Chief Medical Director. 

Facilitators of IET: Clinical leaders acknowledged that health plan case managers play a 

substantive role in engaging members in care. One of their case managers who is an SUD 

specialist has joined the clinical staff in weekly rounds meetings, which has improved their 

ability to assess member risk and recovery progress. Systems leaders also believe that their 

discharge planning and coordinator program is successful in ensuring follow-up after 

hospitalization for SUD issues. 

Barriers to IET: Clinical leaders acknowledged that a lack of screening for SUD by providers was 

a significant barrier to getting more people to initiate and engage in treatment. SBIRT currently 

is not well reimbursed in the state. To alleviate this, the local plan has undertaken its own pilot 

SBIRT initiative with one provider for children and adolescents, which will hopefully expand to 

adults and in other settings. Additionally, PCPs often do not engage in ongoing conversations 
A-42

about SUD risks with their patients, which is a barrier to patients engaging in care to make 

behavior changes. 

Plan leaders and providers also acknowledged that the state Medicaid benefits for SUD are a 

major determinant for access to care. Reimbursement by the health plan is limited by the 

scope of Medicaid coverage within the state, which has not expanded Medicaid. The state’s 

Medicaid program covers a limited population and does not reimburse for detoxification, 

residential care, IOP, or partial hospitalization, although it has limited exceptions for pregnant 

women. 

Quality Improvement Methods: Like the overall governance structure, quality improvement 

decisions and initiatives are largely centralized at the corporate office then implemented by 

local operational and clinical leadership. The corporate office’s government business division 

approves quality improvement initiatives and utilization management decisions and conducts 

annual member and provider satisfaction evaluations as well as state and HEDIS measure data 

analytics. Leaders of the health plan believe that centralized efforts are more efficient and they 

also view this centralized operation as a way to spread the use of best practices across local 

plans. 

The health plan’s Corporate Clinical Quality Management group supports the local plan’s quality 

programs by writing annual quality templates for them to use and to build their local programs. 

Local quality leaders who report to the health plan medical director are accountable for planspecific outcomes. However, the corporate behavioral health team also is responsible for 

HEDIS performance. 

The corporate team is planning to launch an incentive program with a pay-for-performance 

arrangement for SUD providers in 2017. The team is developing a uniform program that will 

support this plan and metrics for evaluation will be developed. The local plan is involved in a 

state value-based purchasing initiative, which allows for both incentive and penalty payments. 

Benefit Design: The health plan benefit array is identical to the state Medicaid benefit, which 

lacks a complete SUD care continuum. The state’s current Medicaid program will only 

reimburse for detoxification and residential treatment services for pregnant women. As noted 

above, the plan coverage currently does not include IOP or partial hospitalization. The health 

plan employs an SUD specialized case manager to coordinate care for all members. Suboxone, 

methadone, and Narcan are covered without prior authorization. Vivitrol requires prior 

authorization. 

Reimbursement: The health plan receives a per member per month rate and is required to 

spend at least 90 percent of this reimbursement on medical services and no more than 10

percent of it on administrative services. Provider reimbursement rates are defined in provider 

contracts. Changes such as enhancing services are met with requests for additional 

reimbursement from providers. Offering incentives or penalties or adding service requirements 

for providers runs into challenges because of reimbursement rates. All provider incentive 
A-43

programs are developed at the corporate level and local plans can implement them, but 

providers must accept them. The rate to out-of-network providers depends on the state. 

Single-case agreements are needed to cover each of the out-of-network providers who are not 

reimbursed at 100 percent because then there would be no incentive for them to come innetwork. 

Network Adequacy: Interviewees expressed frustration over a general shortage and 

underutilization of psychiatrists in SUD service delivery in addition to the inability to reimburse 

for detoxification and other services not covered by the state Medicaid program. The health 

plan also expressed frustration over how few local MAT providers were willing to take on 

Medicaid patients. The state health plan is not engaging in telehealth services that may assist 

with provider shortages.

The plan conducts annual geo-access assessments to identify gaps in care by ZIP Code. Overall, 

the plan has saturated the market by contracting with all available SUD providers. Nonetheless, 

more SUD providers are needed to meet plan needs. 

Market and Beneficiary Characteristics: The health plan covers a large area in a diverse state 

with large urban areas and rural areas that differ greatly. The largest industries are tourism, 

agriculture, health care, and aerospace. The substances most commonly seen in treatment are 

alcohol, heroin, and crack cocaine. Young people also are presenting because of synthetic 

marijuana and bath salt use. Prescription opioid use is more limited as the state responded to 

the initial prescription problem earlier than many other states. Use of PDMPs and plan 

restrictions on pill quantity and number of prescriptions has curtailed prescription opioid 

analgesic use.
A-44

Site Visit Debrief: SITE ID 2003 

The Truven Health research team conducted site visit interviews with health plan ID 2003 

between April 27, 2017 and April 27, 2017. During the site visit, the research team met with 

the health plan’s systems leaders, behavioral health team, and provider contracting and plan 

product development team described in Table F.3. 

TABLE F.3. Site Visit Interviewees for Health Plan ID 2003

Type of Interview Interviewees No. of People

Interviewed

Systems leaders President of Public Plans

Chief Medical Officer of Public Plans

Vice President of Finance, Network and Business 

Performance of Public Plans

Vice President of Care Management of Public Plans

Vice President of Community Relations and Product 

Management for Public Plans

5

Behavioral health 

team

Behavioral Health Medical Director for Public Plans

Director of Behavioral Health for Public Plans

Manager of Integrated Care Management for Public Plans

3

Provider contracting 

and plan product 

Director of Provider Contracting for Public Plans

Product Manager for Public Plans

2

A summary of key findings is included below.

Health Plan Description: This site visit was conducted with a Medicaid plan located in a New 

England state. This Medicaid managed care plan (MCO) plan is a part of a larger health plan 

enterprise consisting of three primary business lines including general commercial products, 

senior-focused products, and public plan products. The plan’s Medicaid MCO falls under its 

public plan product line. As one of the state’s six MCOs, this plan covers approximately 230,000 

lives across all but one small region of the state. 

The public plan’s business line is governed by a public plans-specific leadership rather than 

overarching leadership at the enterprise level. The public plans business also has its own 

behavioral health and care management teams that provide services and direction for the 

Medicaid MCO. 

Facilitators of IET: Interviewees attributed much of their success on the initiation and 

engagement in SUD treatment measures to the health plan’s overall business philosophy. 

Interviewees described an overarching plan attitude that promotes respect for the plan’s 

beneficiary membership and focuses on addressing the unmet needs of underserved 

populations. Systems leaders described their approach as taking the “long view” of SUD 

treatment that starts with identifying individual member needs and continuously providing 

appropriate supports over time to help them engage. Several interviewees highlighted 

examples of the health plan’s providers reaching out to individual members to address their 
A-45

specific unmet housing-related needs and to provide them with motivation to engage in SUD 

treatment services. 

Recently the state Medicaid authority changed the way beneficiaries affiliate with MCOs. 

Instead of being able to change MCOs whenever they want, Medicaid beneficiaries now are 

locked into receiving coverage from one MCO for a full 12 months. This new policy change is 

viewed as a facilitating mechanism for ensuring care managers can follow-up and monitor the 

ongoing and long-term treatment needs of the covered population. It also addresses a 

treatment barrier whereby beneficiaries would be “locked-out” of receipt of opioid 

prescriptions and would simply change to a plan with which they had no history.

Many of the identified facilitators for beneficiary initiation and engagement in SUD treatment 

are quality improvement programs that were developed after 2014, the year for which we 

monitored their performance measures. These additional initiatives are discussed below under 

“quality improvement.”

Barriers to IET: Interviewees considered their delay in learning about member admissions the 

biggest challenge to engaging them effectively in subsequent SUD care. No prior authorization 

is required when members enter a detoxification facility; therefore, the plan generally does not 

learn of the clinical episode until the member is discharged or later. Behavioral health team 

members said that, even when they phone detoxification facilities to inquire about their 

members, the facility’s staff are unwilling to provide any information. Interviewees said that 

many acute treatment facilities interpret state and federal health care privacy laws differently 

and use these laws to avoid engaging with the health plan care managers. 

Interviewees also expressed challenges in identifying SUD inpatient and residential facilities 

that would accept pregnant women. The interviewees reported that providers are 

uncomfortable treating pregnant women, especially those on MAT. The plan does not engage 

its providers in any quality improvement or SUD education-focused initiatives because these 

providers would be overwhelmed. Many of the health plan’s contracted providers have large 

patient volumes and are contracted to provide services to Medicaid beneficiaries under the 

other five MCOs. Thus, it does not seem possible to ask providers to undertake any new SUDfocused initiatives. 

Homelessness is another major barrier to engaging members in treatment. The lack of a stable 

address serves as a barrier to care managers conducting outreach with these members 

following hospital admissions. 

A general lack of step-down treatment also was identified as a major barrier to keeping 

members engaged in care after detoxification services. Although the interviewees felt there is 

sufficient access to acute treatment, they identified residential treatment and MAT prescribers 

as major treatment gaps. 
A-46

Quality Improvement Methods: Since 2014, the year of our data on HEDIS IET measures, the 

health plan has developed more programmatic ways to encourage initiation and engagement in 

care. The health plan has focused on hiring more experienced care management staff and on 

establishing a formal quality improvement process that actively assesses member needs. 

Through this process, the plan has developed several initiatives described below.

The health plan employs an SUD navigator whose job it is to serve as a resource to any member 

with an SUD as well as any family members needing support to ensure they are familiar with 

their benefits and are aware of which SUD treatment programs are in their area. The health 

plan also employs master’s level behavioral health care managers, medical care managers, and 

clinical community specialists who will outreach to members in the hospital or in the 

community. Care managers monitor member admissions and aim to conduct a face-to-face 

visit with the member before he or she is discharged. Their goal is to serve as a point of 

continuity as the member graduates through the continuum of SUD care. Interviewees noted 

that they were unaware of any other Medicaid MCO in the state that provides this predischarge 

service to its members. Additionally, the health plan employs utilization management staff who 

not only review service initiation but also monitor member treatment plans to ensure members 

are accessing services they need. 

Weekly meetings bring together the health plan’s senior leadership, physicians, care managers, 

and SUD navigator to discuss individual high-need members. These meetings are used to 

identify individual cases where the health plan may provide additional support beyond what 

currently is reimbursed under Medicaid. For example, interviewees described how the plan’s 

resources were used to provide the support one member needed to regain custody of her 

newborn following her successful completion of an SUD treatment program. 

The health plan also recently began encouraging members to use a smartphone application 

that allows users to have instant access to support groups and online case management 

services. 

Benefit Design: The health plan benefits are dictated by and match those outlined in the state 

Medicaid authorities’ list of covered services. Covered services include detoxification, 

inpatient, outpatient, IOP, and partial hospitalization services as well as a day treatment 

program for pregnant mothers. MAT also is a covered benefit for all alcohol-related and opioidrelated medications including methadone, buprenorphine/Suboxone, Vivitrol, and 

acamprosate. Although naloxone is a plan benefit, members must pay a co-pay to receive this 

medication. Crisis services are provided through the state emergency services program. Any 

Medicaid beneficiary in the state needing crisis services is guaranteed a full evaluation within 1 

hour of request, either in a hospital or community location. 

The plan is not using telehealth services to meet its members’ SUD needs. Per the plan, the 

provider community has not been receptive to telehealth technology because they would be 

paid less than if they just had the client come in for an in-person visit. The plan believes that 
A-47

even rural beneficiaries live within 90 minutes of a behavioral health provider, so geographic 

access is not a significant barrier in receiving services. 

Reimbursement: Contracted providers operate under a fee-for-service payment model. Both 

in-network and out-of-network providers are reimbursed at generally the same rates as 

outlined by the state Medicaid authority. The plan will, on a case-by-case basis, contract 

certain providers for enhanced rates when those providers are deemed to offer a substantive 

benefit to the health plan. For example, the plan may reimburse providers at 105 percent of 

the standard state Medicaid rate if those providers are serving an area with low network 

adequacy or if the providers have become known as “the provider to see” for quality services. 

The health plan must submit a special request to the state Medicaid authority to contract 

providers for rates above 105 percent, so such arrangements are not frequently made.

Network Adequacy: The health plan is required by the state to conduct geo-access 

assessments identifying gaps in care as well as time and distance to providers. The plan is 

meeting all of its NCQA standards for access. However, interviewees suggested that the 

defined access standards differ from what their actual member population needs. For example, 

although the state has contracted with all the existing providers in one of its more rural areas 

and meets access requirements, the interviewees still felt there are not a sufficient number of 

providers in this area to meet all the plan’s member needs. Interviewees also felt that there is 

a dearth of step-down services available once members are discharged from detoxification 

facilities. 

Market and Beneficiary Characteristics: This health plan serves Medicaid beneficiaries in all 

but one small region of the state. The state is geographically diverse with both large urban and 

rural areas. The largest industries are health care and institutions of higher education. The 

substance uses that are most commonly seen in treatment are alcohol, heroin, fentanyl, and 

prescription opioids. The state has made addressing the opioid epidemic a priority issue and 

has significant legislative support for new and ongoing initiatives related to expanding access to 

SUD treatment and prevention. First responders including police departments also are highly 

involved in facilitating access to SUD treatment. However, the interviewees described 

community stigma as a major hurdle for disseminating SUD prevention and treatment 

education, but they indicated that it seems to be more pronounced in the affluent, nonMedicaid populations than in the Medicaid population served by this plan. 
A-48

Site Visit Debrief: SITE ID 9522 

The Truven Health research team conducted virtual site visit interviews with health plan ID 

9522 on 05/09/2017. During the site visit, the research team met with the health plan’s 

systems leaders, behavioral health team, and quality improvement team staff described in 

Table F.4. 

TABLE F.4. Site Visit Interviewees for Health Plan ID 9522

Type of Interview Interviewees No. of People

Interviewed

Systems leaders Behavioral Health Medical Director

Director of Plan Operations

2

Behavioral health 

team

Manager of Behavioral Health Services 1

Quality 

improvement team

Director of Quality 1

A summary of key findings is included below.

Health Plan Description: This site visit was conducted with a Medicaid plan located in the 

Midwest. This Medicaid MCO plan operates under a regional name but is a part of a larger 

health plan enterprise. Much of the regional plan’s directions and initiatives are provided or 

developed at the local level rather than by the corporate office. The behavioral health team 

reports directly to the local plan’s Medical Director and indirectly to the corporate leadership. 

Corporate leadership acts mostly as a consultant to support the regional plan with quality 

improvement or behavioral health-related initiatives. 

This MCO is one of several serving the state Medicaid population and thus has substantial 

market competition. However, it represents one of the smaller MCOs with approximately 

65,000 covered lives largely concentrated in the state’s more urban areas.

Facilitators of IET: Co-location of the regional plan’s three case management teams--SUD, 

physical health, and utilization management--was cited as one of the plan’s major facilitators 

for effectively coordinating services and keeping members engaged in care. All three teams are 

housed locally and engage in biweekly meetings to discuss members who may need support 

from one or more of the teams. The behavioral health and utilization management teams also 

meet regularly to review inpatient cases and plan for discharge. The behavioral health case 

management team conducts biweekly internal meetings to discuss hard-to-reach members or 

challenging cases with the Behavioral Health Medical Director. Case managers actively engage 

in face-to-face meetings with members in the community to identify their needs and follow-up 

on reasons for missed appointments. Case managers have developed positive relationships 

with several emergency rooms, which have resulted in emergency room staff reaching out and 

alerting the health plan that its members are receiving treatment and facilitating in-person 

meetings in the hospital. 
A-49

The health plan also compiles provider score cards to monitor PCP performance and access. 

When physicians are identified as not promoting sufficient access (e.g., restricted office hours, 

delayed appointments), the health plan conducts private, individual meetings to clarify contract 

requirements. 

Barriers to IET: Competing demands for both physical health and basic necessities, such as 

housing and transportation, serve as major barriers to engaging in treatment. Although the 

health plan can provide transportation services to its members, the state does not allow 

Medicaid members to bring their children in the vehicle. This prevents many parents from 

engaging in services when they cannot secure day care services. Additionally, poor network 

adequacy for MAT is viewed as a major barrier to ensuring access to care for members. The 

health plan is actively reaching out to identify new prescribers or prescribers accepting new 

patients, but statewide access remains problematic.

Quality Improvement Methods: The health plan actively monitors all members who are 

admitted for inpatient treatment. They compile an inpatient census list to discuss these cases 

during case management meetings and to conduct member benchmarking. The plan is using an 

electronic case management system that allows the behavioral health team to monitor 

individual patient needs including physical health status and to identify ways to improve care 

coordination and encourage engagement in treatment. The behavioral health case 

management and utilization management teams also meet regularly to discuss treatment and 

discharge plans, ensuring patients receive services to meet all their clinical and recovery 

support needs. 

Benefit Design: Health plan benefits largely mirror the state Medicaid benefit array. The state 

Medicaid authority does not permit reimbursement for residential treatment programs, so the 

health plan must refer its members to the county for those services. The plan does provide 

coverage for other SUD services including outpatient, inpatient, and partial hospitalization 

services; MAT; and transportation to clinical services. However, prior authorization is required 

for IOP and partial hospitalization services. The state Medicaid authority permits 

reimbursement for peer support services for the SSI population, although the health plan 

currently is not providing these services to its members. 

Reimbursement: The health plan is paid a capitated rate for its member population. The state 

Medicaid authority takes a withhold of 2.5 percent (approximately $3.5-$4 million), giving the 

plan the opportunity to earn the full rate back on the basis of their performance across 12-14 

quality measures; four of these measures are related to SUD, including tobacco. The plan is 

eligible to earns its full withhold if it meets the high-performance goal and 50 percent if it 

meets the medium performance-goal, but it earns 0 percent for lower performance. The plan 

also can earn part of the withhold for improvement rather than just attainment. The plan does 

not have a set shared savings plan to allocate earnings. Instead it focuses its resources on 

addressing the measure or performance service area where it performed the poorest. 
A-50

In-network and out-of-network providers are reimbursed at the state Medicaid rates. In caseby-case situations, the health plan may decide to reimburse providers at an enhanced rate 

depending on the out-of-network need. An alternative payment methodology, determined by 

the state, is applied to providers working in low-capacity areas. 

Network Adequacy: The state Medicaid authority requires that the MCO achieve network 

adequacy standards for time and distance to providers. The health plan is having difficulty 

achieving network adequacy in the state’s more rural counties. Generally, there is a shortage of 

outpatient detoxification providers that results in the health plan’s referring its members to 

inpatient detoxification services. There also is a dearth of buprenorphine prescribers in the 

state, which poses network adequacy challenges. On a quarterly basis, the behavioral health 

and provider relations team reach out to all DATA 2000-licensed providers in the state to 

determine if they can accept new patients. Most prescribers are not accepting new patients. 

The plan currently is not using telehealth to augment its network access but is actively looking 

into expanding into this capability. 

Market and Beneficiary Characteristics: The health plan serves a predominately urban and 

suburban Medicaid population. Several interviewees highlighted socioeconomic challenges of 

the plan’s covered population including transportation needs and homelessness. Drug use in 

the coverage area mirrors national trends, with high rates of OUDs as well as a steady rate of 

alcohol use disorders. Interviewees were unable to say whether there was more prescription 

opioid or heroin use, but indicated that both are present.
A-51

Site Visit Debrief: SITE ID 8200 

The Truven Health research team conducted site visit interviews with health plan ID 8200 on 

June 1, 2017. The research team interviewed the health plan’s systems leaders, a key leader for 

behavioral health initiatives, the plan’s quality improvement team, and core leaders in case 

management. 

TABLE F.5. Site Visit Interviewees for Health Plan ID 8200

Type of Interview Interviewees No. of People

Interviewed

Systems leaders Assistant Director of Regional Mental Health and Chief of 

the Department of Psychiatry 

Chief of Addiction Medicine

2

Behavioral health 

leader

Chief of Addiction Medicine 1

Quality 

improvement 

leaders

Program Director

Medical Group Physician

Managerial Consultant for Quality and Operations Support 

3

Case management 

leaders

Licensed Psychologist (2)

Marriage and Family Therapist 

3

A summary of key findings is included below.

Health Plan Description: This site visit was conducted with a commercial plan located in the 

West. This health plan functions as an integrated model, providing both health insurer and 

medical group services to its covered lives. Thus, the plan is a very physician-led one. This large 

national plan is organized into distinct regions, each with local oversight and decision-making 

power for behavioral health and quality improvement initiatives. This federated model enables 

the plan to adapt to its local population needs. 

Facilitators of IET: The health plan implemented universal SUD risk screening in primary care 

settings, which has enabled it to provide more early intervention services and facilitated 

initiation in SUD treatment as well. SBIRT prompts were embedded in the plan’s electronic 

medical record to improve use. The health plan also has identified physician champions in each 

of its medical centers to encourage other providers to screen and refer patients to local 

addictions and recovery clinics operated by the health plan. 

However, the plan did find that providers were overdiagnosing patients, which inappropriately 

inflated the number of beneficiaries who needed to be engaged in services. The plan created 

new internal codes that allowed physicians to mark patients as engaging in risky use without 

designating them as having a diagnosed SUD. Reducing the number of inappropriately 

diagnosed beneficiaries helped the plan to target resources and improve on the engagement 

measure. 
A-52

Each medical practice under the health plan generates a daily “Best Practice Alert” report for 

each physician in the practice. This report contains a list of all patients with SUD diagnoses and 

a note indicating whether the patient is in treatment, has a referral, or still needs a follow-up 

from the physician regarding a referral or change of diagnosis. The physician champion uses 

this list to create a fall-out list of all patients who need follow-up services. The champion then 

meets with these patients’ providers to remind them of the follow-up and other clinical 

requirements. The health plan also generates provider report cards that rank each physician’s 

performance in providing follow-up services against the performance of other physicians in the 

medical group. 

Immediate access to services was identified as another facilitator of treatment initiation and 

engagement. Because of the integrated model and service requirements set by the insurer, 

salaried providers are unable to place any beneficiaries on a waitlist for services. All 

beneficiaries requesting SUD treatment services must be seen within 2 days. Approximately 25

percent of beneficiaries receive same-day services. 

Barriers to IET: Physicians cited lack of new SUD treatment providers joining the field as a 

major barrier. They are worried that network adequacy is not sufficient to meet beneficiaries’ 

growing demands, especially in rural areas. They are seeing a major shortage of psychiatrists in 

their network. Sufficient access to residential treatment beds also are a concern for the plan. 

The plan provides partial hospitalization and outpatient services through its own medical 

groups, but must contract with external facilities to provide residential care. Additionally, 

several providers cited members’ stigma about SUD diagnoses as major barriers to engaging in 

care. 

Quality Improvement Methods: The health plan’s medical group oversees all quality 

improvement activities around the HEDIS measures and other SUD treatment initiatives. The 

plan enables physician practice leaders to implement initiatives specific to their local population

needs. The plan has a health services research team and contracted consultants to help 

identify implementation strategies promoting evidence-based practices. The health plan 

generally prefers to pilot implementation strategies in one of its practice settings before rolling 

the strategy out across its entire covered region. 

The plan also cited the ability to mine its internal database to identify missed follow-up 

appointments and other beneficiary trends in service utilization. These trends are then acted 

upon with interventions designed and implemented by the local physician practice.

Benefit Design: All pharmacy, behavioral health, and SUD treatment benefits are organized by 

the health plan. There are no prior authorizations for any SUD treatment services. The plan 

does not have any specified medical necessity criteria for service provision, so all services are 

available to plan beneficiaries. 

The plan delivers SUD treatment services through community addiction and recovery programs 

that may be organized as any of the following: partial hospitalization, IOP, and outpatient 
A-53

providers. Residential services are contracted with community facilities and provided for 60 

days. MAT is available to all plan members. The plan directly provides buprenorphine and 

naltrexone (oral and injectable) in its community addictions and recovery programs. However, 

methadone services are provided through contracts with external providers. It was decided 

that the plan would not dispense methadone directly because of the federal requirements 

associated with clinic infrastructure. Beneficiaries at risk for overdose can receive two units of 

naloxone so that they and a family member may carry the medication. 

Reimbursement: The health plan operates as a membership organization with a per member 

per month capitated rate designated for each region. Although providers are affiliated with 

physician groups, they are contracted as salaried employees of the health plan. Because of its 

highly integrated model and extensive benefit array, the health plan has little need to contract 

with out-of-network providers. If the plan does contract with out-of-network providers, it 

generally reimburse these providers at the state Medicaid rate. 

Network Adequacy: Interviewees felt that the health plan currently is meeting the network 

adequacy needs of its covered population. The state where the plan operates sets maximum 

mileage and travel time requirements for accessing care, which currently are being met. 

Additionally, the health plan has internal requirements to provide 2-day access for urgent care 

and 14-day access for non-urgent care services. Interviewees said that the plan currently is 

meeting those requirements, and a substantial portion of urgent care members are seen on the 

same day as their request. 

However, there were worries that the SUD treatment workforce is not growing as quickly as the 

population’s needs. Although the plan is using a substantial amount of telehealth services, its 

primary impetus was to provide members with more appointment flexibility rather than to 

solve access issues. Providers can conduct follow-up and brief consultation visits with members 

via secure video connections. However, the plan is not pushing for more use of these services 

to increase access in rural areas. 

Market and Beneficiary Characteristics: The health plan is the largest HMO in the state and 

thus serves a geographically and demographically diverse population. The plan region is vast 

and includes several local medical centers with different provider groups in rural and urban 

areas. Most plan beneficiaries are employed and the plan contracts as the medical insurer to 

several city and state government agencies.
A-54

Site Visit Debrief: SITE ID 4019 

The Truven Health research team conducted site visit interviews with health plan ID 4019 on 

June 5-6, 2017. As described in Table F.6, the research team interviewed the health plan’s 

systems leaders, a key leader for behavioral health initiatives, the plan’s quality improvement 

team and core leaders in case management.

TABLE F.6. Site Visit Interviewees for Health Plan ID 4019

Type of Interview Interviewees No. of People

Interviewed

Systems leaders Plan Presidents (2)

Senior Vice President of Operations

3

Behavioral health 

leader

Chief Medical Officer

Medical Director of Behavioral Health

Director of Clinical Operations

3

Quality 

improvement 

leaders

Director of Population Health Strategies

Vice President of Quality Improvement

Corporate Director of Quality and Performance 

Improvement

Senior Manager of Quality Improvement

Senior Manager of Quality Improvement Strategy

5

Network adequacy 

leaders

Director of Network Development

Manager of Network Development for Behavioral Health

Provider Network Development–Behavioral Health Team 

Lead

Senior Vice President of Utilization Management

Director of Behavioral Health Utilization Management 

5

Care coordination 

leaders

Senior Director of Care Coordination

Senior Managers of Care Coordination (2)

Manager of Behavioral Health and Care Coordination

Manager of Care Coordination

Director of Community Care Coordination

Behavioral Health Community Care Coordinator Team 

Leads (2)

8

A summary of key findings is included below.

Health Plan Description: This site visit was conducted with a Medicaid managed care plan 

located in the Midwest. The plan operates with local state leadership and corporate leadership 

based out of a neighboring state. The plan has several state Medicaid plans, which prompted 

them to adopt a philosophy of managed care operationalized by local plan leaders that 

communicate with the local providers and beneficiaries. Behavioral health care coordination is 

organized both locally and centrally by the corporate office. The national plan can centrally 

locate some of its behavioral health efforts (e.g., phone outreach for care coordination) but 

largely values a “boots on the ground” approach by local providers. 
A-55

Facilitators of IET: The health plan actively analyzes its internal pharmacy data to identify 

beneficiaries who exhibit indicators of undiagnosed behavioral health care needs. The 

corporate office generates a monthly report identifying any members that fill three or more 

narcotic prescriptions at three or more pharmacies that are written by three or more 

prescribers. The members identified in this report are reviewed for potential member safety 

concerns. In addition, cases are reviewed if care coordination services are being provided or if 

a care coordination referral is appropriate for these individuals. 

The plan also uses its EHR data to identify when members are admitted for a SUD diagnosis. 

Behavioral health coordinators can reach out as soon as they get the notification from the 

facility. Plan-contracted providers also may use their provider portal to refer a member for care 

coordination services with one click. The health plan care coordination team is notified 

instantly and conducts outreach to the member.

Care coordinators pointed to the plan’s focus on identifying community support services where 

the members live as a major facilitator to treatment engagement. Because members often will 

not engage in care that is not provided in their local neighborhoods, finding the right resources 

nearby is critical to the plan’s approach. Plan providers also believe that developing trusting 

relationships between members and the care coordination team through face-to-face outreach 

and regular phone calls is critical to successfully engaging members in care. Members might 

not be ready for treatment at the first outreach, but the care coordination team will persist and 

regularly follow-up to conduct motivational interviewing that promotes treatment engagement.

Barriers to IET: The health plan identified the timeliness of service use notifications as a major 

barrier to being able to provide immediate outreach to their members. Such notifications of 

outpatient service utilization often occur after the 14-day follow-up period, which reduces the 

plan’s ability to conduct outreach and engage the member in care. There has been substantial 

improvement with this delay, but the issue remains a work in progress. This is of particular 

concern when members enter detoxification facilities or other facilities familiar with 42 CFR 

Part II. Staff at inpatient SUD treatment and detoxification facilities often tell the plan’s care 

coordinators that they will not share records or provide notifications of members’ admissions 

because of 42 CFR Part II restrictions. One plan representative indicated that non-specialized 

facilities are more likely to reach out because they are less familiar with 42 CFR and tend to 

follow the Health Insurance Portability and Accountability Act (HIPAA) requirement that allows 

them to communicate with the payer. When asked, the plan representative indicated that the 

recent changes to 42 CFR do not change matters for health plans and do not improve their 

ability to coordinate care for members.

Interviewees identified the state’s transition from siloed behavioral health services to 

embracing Medicaid managed care as a major barrier to providers truly understanding how the 

health plan can help care for their population. They cited provider knowledge of managed care, 

care coordination, and other outreach services as barriers they are actively addressing with 

educational efforts and trainings. 
A-56

Finding accurate contact information for beneficiaries is another barrier to engaging them in 

care. Many members become unreachable because they frequently change their phone 

number or address. General stigma around SUDs and members not wanting to be associated 

with that diagnosis is another barrier to engaging them in care, particularly in standalone 

facilities. 

Quality Improvement Methods: The health plan actively works with subject matter experts 

and takes advantage of SAMHSA and American Psychiatric Association educational webinars to 

stay current on evidence-based practices. The health plan has started to approach quality 

improvement from a population health perspective. It is using the Johns Hopkins ACG® System 

to stratify and segment its covered lives from the healthiest to the sickest members on the 

basis of their illness burden. From there, the health plan is able to allocate members to receive 

specific clinical interventions based on needs. This approach is helping the plan identify the 

health needs of their moderate-risk or moderately unhealthy members and target them before 

their risks increase. 

Benefit Design: The health plan benefit design is matched to that of the state Medicaid benefit 

array. Because prior authorization often causes barriers to accessing necessary services, all 

MATs are provided as covered benefits and do not require prior authorization. Naloxone also is 

covered under the plan benefit. Peer support services are not included as a state Medicaid 

benefit and therefore are not offered by the plan. The plan also is not providing telehealth 

services for any behavioral health care at this time. According to the interviewees, no providers 

have requested to use these services in rural areas, and the plan is concerned about the privacy 

requirements and costs associated with providing telehealth. 

Reimbursement: The plan receives a capitated per member per month rate and a 

performance-based withhold dependent on its HEDIS and CAHPS performance. The IET 

measure is considered a bundled measure in the state, so this Medicaid plan must perform well

on both the initiation and engagement aspects of the measure to receive its withhold payout. 

The measure also is bundled with all other HEDIS measures, and the plan must meet all 

benchmarks in order to receive the withhold.

Providers are paid fee for service. The health plan reimburses providers at 100 percent of the 

state Medicaid rate. The plan generally does not contract with out-of-network providers; 

however, if needed, the plan will use the state Medicaid rate as the baseline negotiation. The 

state is piloting a value-based payment arrangement with community mental health centers, 

but the arrangement is not specific to SUD treatment services. 

The state budget crisis is having a significant impact on the health plan’s ability to reimburse 

providers. The state owes a substantial sum of back Medicaid reimbursements to the plan, 

which in turn owes reimbursements to its provider network. Many Medicaid-only providers are 

unable to stay in business and several have stopped seeing Medicaid patients. The state has 

also kept the Medicaid reimbursement rate in flux, raising and lowering the rate, because of its 

budget crisis. 
A-57

Network Adequacy: Interviewees reported that there are concerns about a shortage of 

psychiatrists and addiction-certified providers coming into the field to replace the retiring 

professionals. Executive leadership does not identify a shortage of MAT prescribers, but care 

coordinators report having a difficult time identifying prescribers willing to accept new patients, 

particularly in rural areas. SUD treatment services for adolescents and pregnant mothers also 

are scarce throughout the state. Most of the services targeting special populations are located 

in urban areas. 

Market and Beneficiary Characteristics: The health plan serves Medicaid beneficiaries residing 

in all regions of the state. Despite growing use of prescription opioid and heroin, alcohol 

remains the most prevalent substance of misuse and abuse for the plan’s membership. Cocaine 

also is commonly used among the plan’s SUD population. Many of these individuals also have 

co-occurring physical health or mental disorders including schizophrenia. 
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RETURN TO:

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http://aspe.hhs.gov/office-disability-aging-and-long-term-care-policy-daltcp

Assistant Secretary for Planning and Evaluation (ASPE) Home

http://aspe.hhs.gov

U.S. Department of Health and Human Services (HHS) Home

http://www.hhs.gov