By Alison Knopf
States that have Medicaid funding for methadone treatment are far more likely than states without such funding to have Medicaid-enrolled patients in treatment programs, researchers have found. In 17 states, however, Medicaid does not pay for methadone treatment.
For the study, “Medicaid Coverage for Methadone Maintenance and Use of Opioid Agonist Therapy in Specialty Addiction Treatment,” the researchers analyzed the 2012 Treatment Episode Data Set (TEDS) from the Substance Abuse and Mental Health Services Administration. They used a sample restricted to individuals who were covered by Medicaid and admitted to treatment primarily for opioid use disorders.
In states with Medicaid coverage for opioid agonist therapy, 45% of individuals enrolled in Medicaid used the opioid agonist therapy, compared to 30.1% of individuals enrolled in Medicaid in states with only Substance Abuse Prevention and Treatment (SAPT) block grant funding, and 17% of Medicaid-enrolled individuals in states with no public coverage.
Opioid agonist therapy is treatment with methadone or buprenorphine—the TEDS system does not distinguish between methadone and other opioid addiction treatment, but states do make this distinction. Both methadone and buprenorphine are effective, and buprenorphine is now covered in every state Medicaid program, but methadone is not. Furthermore, Medicaid funding for methadone treatment is already under fire in some states.
The information on methadone treatment came from a survey mailed to Medicaid programs in all 50 states and the District of Columbia, on behalf of the American Society of Addiction Medicine (ASAM). The Society categorized states into three groups, by method of payment for methadone treatment: 1) via Medicaid; 2) only through a SAPT block grant; and 3) no public coverage. (States that had both Medicaid and SAPT block grant coverage were categorized under Medicaid.)
The researchers connected the state reimbursement measures to the 2012 TEDS, which includes information on 1.7 million public-sector substance abuse treatment admissions. TEDS covers treatment setting, substances used, history of use, and demographics, but does not indicate which medication, methadone or buprenorphine, is administered. Nationally, 98% of people in opioid treatment programs (OTPs) receive methadone. Reporting insurance status is not required in TEDS, but insurance status was indicated in 36 states in 2012.
The researchers looked only at Medicaid enrollees admitted to treatment for opioid use disorders in those states, and excluded detoxification admissions. They focused on the differences in the use of agonist medications across three settings: residential, intensive outpatient, and non-intensive outpatient. Intensive outpatient treatment generally involves more time spent in the facility, up to several hours every day. Most opioid agonist therapy is delivered in non-intensive outpatient settings.
Settings for Opioid Agonist Therapy Under Medicaid*
|Anything less than intensive outpatient
Includes ambulatory treatment services (individual, family, and/or group services; may include pharmacological therapies)
|At a minimum, 2 or more hours’ treatment/day for
3 or more days/week
|Individuals stay overnight, either in a hospital or in a non-acute care setting, with clinical supervision (not detoxification)|
*Definitions of outpatient treatment settings used by TEDS.
Overall, 7% of all Medicaid enrollees received opioid agonist therapy in states with no methadone coverage, compared to 46.6% of Medicaid enrollees in states that did have Medicaid covering methadone.
As the table below shows, non-intensive outpatient was the most common treatment setting for patients being treated for opioid use disorders. Fewer than 10% of all patients in residential treatment settings were treated for these disorders.
Percent of Treatment Facilities Receiving Reimbursement for Methadone
|Outpatient Medicaid||64.2||27.0||Three funding sources combined:
|SAPT block grant||40.9||21.8|
|No public coverage for methadone||27.4||9.0|
Most patients were women, especially in states that had no public funding for treatment. It’s important to remember that before Medicaid expansion under the Affordable Care Act, which allowed coverage for men, the vast majority of Medicaid enrollees were women.
In addition, most Medicaid-enrolled patients in opioid agonist therapy were white, although states where the SAPT block grant provided reimbursement also had non-Hispanic black populations in treatment.
Compared to patients in states with Medicaid or SAPT block grant coverage, or both, patients in states with no public coverage were more likely to be in their first episode of treatment. They were more likely to be users of prescription opioid analgesics rather than heroin, but less likely to have used substances daily.
Medicaid as a Driver for Care
Differences across states did not apply to people with commercial insurance who were not affected by Medicaid policies, the researchers found. The researchers suggested that Medicaid coverage of methadone may help drive particular populations—especially heroin users—to treatment.
If a state specifically includes methadone in its Medicaid benefit, all Medicaid recipients can get it. The federal SAPT block grant is next in importance as a source of public funding, but SAPT funds, unlike Medicaid, are provisional and capped. Finally, if public funding is only from non-federal sources, such as the city health department, OTP treatment may not be readily available.
OTPs are the only source of methadone treatment, and are desperately needed in the midst of an opioid epidemic. But OTPs are sensitive to coverage, and can’t stay open if patients can’t afford to pay. For people who need treatment for opioid use disorders, but lack employer-based health insurance, and can’t afford to buy insurance on their own, Medicaid is the safety net.
If Medicaid won’t pay, the study shows, fewer people will avail themselves of treatment—and this may have lasting consequences. For example, after Oregon Medicaid temporarily eliminated coverage for methadone treatment, the number of people accessing treatment programs declined dramatically, and several programs closed.
Limitations of the study. Some Medicaid enrollees may be treated in physician-based office practices, which would not be reflected in the study data. In states that allow Medicaid coverage for buprenorphine, but not for methadone, Medicaid recipients would be more likely to go to office-based providers.
* * *
Saloner B, Stoller K. Medicaid coverage for methadone maintenance and use of opioid agonist therapy in specialty addiction treatment. Psychiatric Services. In press.