E. Behavioral Health (The Hilltop Institute, UMBC)

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Duration of Medication Treatment for Opioid-Use Disorder and Risk of Overdose among Medicaid Enrollees in Eleven States: A Retrospective Cohort Study
(Wiley, 2022-06-02) Burns, Marguerite; Tang, Lu; Chang, Chung-Chou H.; Kim, Joo Yeon; Ahrens, Katherine; Allen, Lindsay; Cunningham, Peter; Gordon, Adam J.; Jarlenski, Marian P.; Lanier, Paul; Mauk, Rachel; McDuffie, Mary Joan; Mohamoud, Shamis; Talbert, Jeffery; Zivin, Kara; Donohue, Julie
Background and aims Medication for opioid use disorder (MOUD) reduces harms associated with opioid use disorder (OUD), including risk of overdose. Understanding how variation in MOUD duration influences overdose risk is important as health-care payers increasingly remove barriers to treatment continuation (e.g. prior authorization). This study measured the association between MOUD continuation, relative to discontinuation, and opioid-related overdose among Medicaid beneficiaries. Design Retrospective cohort study using landmark survival analysis. We estimated the association between treatment continuation and overdose risk at 5 points after the index, or first, MOUD claim. Censoring events included death and disenrollment. Setting and participants Medicaid programs in 11 US states: Delaware, Kentucky, Maryland, Maine, Michigan, North Carolina, Ohio, Pennsylvania, Virginia, West Virginia and Wisconsin. A total of 293 180 Medicaid beneficiaries aged 18–64 years with a diagnosis of OUD and had a first MOUD claim between 2016 and 2017. Measurements MOUD formulations included methadone, buprenorphine and naltrexone. We measured medically treated opioid-related overdose within claims within 12 months of the index MOUD claim. Findings Results were consistent across states. In pooled results, 5.1% of beneficiaries had an overdose, and 67% discontinued MOUD before an overdose or censoring event within 12 months. Beneficiaries who continued MOUD beyond 60 days had a lower relative overdose hazard ratio (HR) compared with those who discontinued by day 60 [HR = 0.39; 95% confidence interval (CI) = 0.36–0.42; P < 0.0001]. MOUD continuation was associated with lower overdose risk at 120 days (HR = 0.34; 95% CI = 0.31–0.37; P < 0.0001), 180 days (HR = 0.31; 95% CI = 0.29–0.34; P < 0.0001), 240 days (HR = 0.29; 95% CI = 0.26–0.31; P < 0.0001) and 300 days (HR = 0.28; 95% CI = 0.24–0.32; P < 0.0001). The hazard of overdose was 10% lower with each additional 60 days of MOUD (95% CI = 0.88–0.92; P < 0.0001). Conclusions Continuation of medication for opioid use disorder (MOUD) in US Medicaid beneficiaries was associated with a substantial reduction in overdose risk up to 12 months after the first claim for MOUD.
Design, Implementation, and Evolution of the Medicaid Outcomes Distributed Research Network (MODRN)
(Wolters Kluwer, 2022-07-15) Zivin, Kara; Allen, Lindsay; Barnes, Andrew J.; Junker, Stefanie; Kim, Joo Yeon; Tang, Lu; Kennedy, Susan; Ahrens, Katherine A.; Burns, Marguerite; Clark, Sarah; Cole, Evan; Crane, Dushka; Idala, David; Lanier, Paul; Mohamoud, Shamis; Jarlenski, Marian; McDuffie, Mary Joan; Talbert, Jeffery; Gordon, Adam J.; Donohue, Julie M.
Background: In the US, Medicaid covers over 80 million Americans. Comparing access, quality, and costs across Medicaid programs can provide policymakers with much-needed information. As each Medicaid agency collects its member data, multiple barriers prevent sharing Medicaid data between states. To address this gap, the Medicaid Outcomes Distributed Research Network (MODRN) developed a research network of states to conduct rapid multi-state analyses without sharing individual-level data across states. Objective: To describe goals, design, implementation, and evolution of MODRN to inform other research networks. Methods: MODRN implemented a distributed research network using a common data model, with each state analyzing its own data; developed standardized measure specifications and statistical software code to conduct analyses; and disseminated findings to state and federal Medicaid policymakers. Based on feedback on Medicaid agency priorities, MODRN first sought to inform Medicaid policy to improve opioid use disorder treatment, particularly medication treatment. Results: Since its 2017 inception, MODRN created 21 opioid use disorder quality measures in 13 states. MODRN modified its common data model over time to include additional elements. Initial barriers included harmonizing utilization data from Medicaid billing codes across states and adapting statistical methods to combine state-level results. The network demonstrated its utility and addressed barriers to conducting multi-state analyses of Medicaid administrative data. Conclusions: MODRN created a new, scalable, successful model for conducting policy research while complying with federal and state regulations to protect beneficiary health information. Platforms like MODRN may prove useful for emerging health challenges to facilitate evidence-based policymaking in Medicaid programs.
Association of polysubstance use disorder with treatment quality among Medicaid beneficiaries with opioid use disorder
(Elsevier, 2022-10-31) Smart, Rosanna; Kim, Joo Yeon; Kennedy, Susan; Tang, Lu; Allen, Lindsay; Crane, Dushka; Mack, Aimee; Mohamoud, Shamis; Pauly, Nathan; Perez, Rosa; Donohue, Julie
Introduction: The opioid crisis is transitioning to a polydrug crisis, and individuals with co-occurring substance use disorder (SUDs) often have unique clinical characteristics and contextual barriers that influence treatment needs, engagement in treatment, complexity of treatment planning, and treatment retention. Methods: Using Medicaid data for 2017–2018 from four states participating in a distributed research network, this retrospective cohort study documents the prevalence of specific types of co-occurring SUD among Medicaid enrollees with an opioid use disorder (OUD) diagnosis, and assesses the extent to which different SUD presentations are associated with differential patterns of MOUD and psychosocial treatments. Results: We find that more than half of enrollees with OUD had a co-occurring SUD, and the most prevalent co-occurring SUD was for “other psychoactive substances”, indicated among about one-quarter of enrollees with OUD in each state. We also find some substantial gaps in MOUD treatment receipt and engagement for individuals with OUD and a co-occurring SUD, a group representing more than half of individuals with OUD. In most states, enrollees with OUD and alcohol, cannabis, or amphetamine use disorder are significantly less likely to receive MOUD compared to enrollees with OUD only. In contrast, enrollees with OUD and other psychoactive SUD were significantly more likely to receive MOUD treatment. Conditional on MOUD receipt, enrollees with co-occurring SUDs had 10 % to 50 % lower odds of having a 180-day period of continuous MOUD treatment, an important predictor of better patient outcomes. Associations with concurrent receipt of MOUD and behavioral counseling were mixed across states and varied depending on co-occurring SUD type. Conclusions: Overall, ongoing progress toward increasing access to and quality of evidence-based treatment for OUD requires further efforts to ensure that individuals with co-occurring SUDs are engaged and retained in effective treatment. As the opioid crisis evolves, continued changes in drug use patterns and populations experiencing harms may necessitate new policy approaches that more fully address the complex needs of a growing population of individuals with OUD and other types of SUD.
Use of Medications for Treatment of Opioid Use Disorder among US Medicaid Enrollees in 11 States, 2014-2018
(JAMA Network, 2021-07-13) Medicaid Outcomes Distributed Research Network (MODRN); Donohue, Julie M; Jarlenski, Marian P; Kim, Joo Yeon; Idala, David; Mohamoud, Shamis; et al
Importance: There is limited information about trends in the treatment of opioid use disorder (OUD) among Medicaid enrollees. Objective: To examine the use of medications for OUD and potential indicators of quality of care in multiple states. Design, setting, and participants: Exploratory serial cross-sectional study of 1 024 301 Medicaid enrollees in 11 states aged 12 through 64 years (not eligible for Medicare) with International Classification of Diseases, Ninth Revision (ICD-9 or ICD-10) codes for OUD from 2014 through 2018. Each state used generalized estimating equations to estimate associations between enrollee characteristics and outcome measure prevalence, subsequently pooled to generate global estimates using random effects meta-analyses. Exposures: Calendar year, demographic characteristics, eligibility groups, and comorbidities. Main outcomes and measures: Use of medications for OUD (buprenorphine, methadone, or naltrexone); potential indicators of good quality (OUD medication continuity for 180 days, behavioral health counseling, urine drug tests); potential indicators of poor quality (prescribing of opioid analgesics and benzodiazepines). Results: In 2018, 41.7% of Medicaid enrollees with OUD were aged 21 through 34 years, 51.2% were female, 76.1% were non-Hispanic White, 50.7% were eligible through Medicaid expansion, and 50.6% had other substance use disorders. Prevalence of OUD increased in these 11 states from 3.3% (290 628 of 8 737 082) in 2014 to 5.0% (527 983 of 10 585 790) in 2018. The pooled prevalence of enrollees with OUD receiving medication treatment increased from 47.8% in 2014 (range across states, 35.3% to 74.5%) to 57.1% in 2018 (range, 45.7% to 71.7%). The overall prevalence of enrollees receiving 180 days of continuous medications for OUD did not significantly change from the 2014-2015 to 2017-2018 periods (-0.01 prevalence difference, 95% CI, -0.03 to 0.02) with state variability in trend (90% prediction interval, -0.08 to 0.06). Non-Hispanic Black enrollees had lower OUD medication use than White enrollees (prevalence ratio [PR], 0.72; 95% CI, 0.64 to 0.81; P < .001; 90% prediction interval, 0.52 to 1.00). Pregnant women had higher use of OUD medications (PR, 1.18; 95% CI, 1.11-1.25; P < .001; 90% prediction interval, 1.01-1.38) and medication continuity (PR, 1.14; 95% CI, 1.10-1.17, P < .001; 90% prediction interval, 1.06-1.22) than did other eligibility groups. Conclusions and relevance: Among US Medicaid enrollees in 11 states, the prevalence of medication use for treatment of opioid use disorder increased from 2014 through 2018. The pattern in other states requires further research.
Innovative Solutions for State Medicaid Programs to Leverage Their Data, Build Their Analytic Capacity, and Create Evidence-Based Policy
(PubMed Central, 2019-08-05) Adams, Lauren; Kennedy, Susan; Allen, Lindsay; Barnes, Andrew; Bias, Tom; Crane, Dushka; Lanier, Paul; Mauk, Rachel; Mohamoud, Shamis; Pauly, Nathan; Talbert, Jeffrey; Woodcock, Cynthia; Zivin, Kara; Donohue, Julie
As states have embraced additional flexibility to change coverage of and payment for Medicaid services, they have also faced heightened expectations for delivering high-value care. Efforts to meet these new expectations have increased the need for rigorous, evidence-based policy, but states may face challenges finding the resources, capacity, and expertise to meet this need. By describing state-university partnerships in more than 20 states, this commentary describes innovative solutions for states that want to leverage their own data, build their analytic capacity, and create evidence-based policy. From an integrated web-based system to improve long-term care to evaluating the impact of permanent supportive housing placements on Medicaid utilization and spending, these state partnerships provide significant support to their state Medicaid programs. In 2017, these partnerships came together to create a distributed research network that supports multi-state analyses. The Medicaid Outcomes Distributed Research Network (MODRN) uses a common data model to examine Medicaid data across states, thereby increasing the analytic rigor of policy evaluations in Medicaid, and contributing to the development of a fully functioning Medicaid innovation laboratory.
Health Home Program Evaluation: CY 2013 to CY 2018
(The Hilltop Institute UMBC, 2021-03-18) The Hilltop Institute
This report is an update to the 2018 Health Home Evaluation Report and the 2015 Joint Chairmen’s Report on Patient Outcomes for Participants in Health Homes. Its purpose is to describe the characteristics and outcomes of participants in the Maryland Health Home program. The Maryland Health Home program for individuals with chronic conditions builds on statewide efforts to integrate somatic and behavioral health services.
Micro-Targeted Computerized Alcohol Misuse Intervention System for Health Care Study
(The Hilltop Institute, 2016-04-04) Boddie-Willis, C.,; Woodward, J.; Vanderwerker, L. C.; Cannon-Jones, S.,; Caldwell, D.
Alcohol misuse has been identified as a major public health problem in the United States. However, although not yet widely adopted, alcohol screening and brief intervention (SBI) in the primary care setting has been shown to reduce problematic alcohol consumption. In order to facilitate SBI for alcohol misuse, Research Circle Associates (RCA), a Maryland-based research firm, obtained a Small Business Technology Transfer (STTR) grant to develop a computerized SBI for use in the primary care setting. The Interventionaire© is a software system used to create and administer patient-based behavioral screening questionnaires and provide normative feedback to patients immediately upon completion of the questionnaire. Following successful proof-of-concept work in Phase I of the STTR, RCA contracted with The Hilltop Institute to conduct a qualitative analysis to address one specific aim of a larger Phase II implementation study: identify staff-perceived barriers to implementing the Interventionaire© in the primary care setting. This report not only identifies staff-perceived barriers to implementing a computerized alcohol SBI tool in a primary care setting, but also identifies potential facilitators and explores anticipated advantages and disadvantages to implementation.
An Analysis of Selected Mental Health Conditions among Maryland Full-Benefit Dual-Eligible Beneficiaries
(The Hilltop Institute, 2016-02-16) Cannon Jones, S.; Stockwell, I.
At the request of the Maryland Department of Health and Mental Hygiene (DHMH), The Hilltop Institute conducted a series of analyses on the health care utilization of Maryland’s full-benefit Medicare-Medicaid dual-eligible beneficiaries. Together, these analyses provide an overview of how this population accesses health care services, the types of services being used, and where the services are provided. This report examines full-benefit dual-eligible beneficiaries with mental health conditions in Maryland during calendar year (CY) 2012, including number and type of mental health conditions; demographics and county of residence; emergency department use; and Medicare and Medicaid expenditures and service days. Related publications: Maryland Full-Benefit Dual-Eligible Beneficiaries’ Use of Medicare and Medicaid Services Preceding and Following a Medicare Inpatient Stay, Characteristics of Maryland Full-Benefit Dual-Eligible Beneficiaries with Three or More Inpatient Stays, and The Maryland Dual-Eligible Beneficiaries Chart Book.
Evaluation of the Maryland Medicaid Chronic Health Homes Program
(2015-06-13) Mohamoud, Shamis; Smirnow, Alexis; Idala, David; Brown, Alyssa
Hilltop staff made several presentations at the 2015 AcademyHealth Annual Research Meeting (ARM) held June 13 through June 15 in Minneapolis. Senior Policy Analyst Shamis Mohamoud, MA, delivered this podium presentation at the State Health Research and Policy Interest Group Meeting.
Health Homes Program Annual Report
(The Hilltop Institute, 2014-10-31) The Hilltop Institute
Health Homes are intended to improve health outcomes for individuals with chronic conditions by providing patients with an enhanced level of care management and care coordination. The goal of this report is to provide a description of Medicaid enrollees’ participation in the Maryland Health Home program and their interactions with the health care system during the first year of program implementation.
Report on Tobacco Use Rating for Health Insurance Policies
(2014-09-01) Kromm, Jonathan; Grason, Catherine
During the 2013 Legislative Session, the Maryland General Assembly passed House Bill 228 (Chapter 159, Acts of 2013), entitled the Maryland Health Progress Act of 2013. Section 6 of Chapter 159 requires the Maryland Health Benefit Exchange (MHBE) and the Maryland Insurance Administration (MIA) to conduct a joint study of the impact of the Affordable Care Act’s allowance of a tobacco use rating of 1.5 to 1, including (1) its effect on insurance premiums generally; (2) its effect on the affordability and purchase of insurance, and access to health care, for tobacco users; and (3) any disparate impact on specific vulnerable populations. The study must further assess the options that may be available to the state to address any adverse consequences of tobacco use rating. Hilltop worked with the MHBE and the MIA to conduct this legislatively mandated study. This report contains the findings of the study and concludes with options for further legislative action.
New Maryland Medicare-Medicaid Enrollees with Mental Health Conditions: Prior Medicare and Medicaid Resource Use
(The Hilltop Institute, 2014-06-25) Stockwell, I.; Tripp, A.
The incidence of mental health disorders co-occurring with chronic somatic health conditions is gaining attention. This combination can pose significant burdens to health care system resources to provide for complex care needs. In this analysis, the prevalence of co-occurring mental health disorders amongst Maryland’s new dual eligible enrollees during 2008 and their subsequent Medicare and Medicaid resource use is explored using the Centers for Medicare and Medicaid Services Chronic Condition Data Warehouse. Mental health conditions were identified in over a third of all new duals in the study population. The most prevalent mental health condition was depression, which affected 24.4 percent of the total study population and 65.0 percent of the subset with a mental health diagnosis. Among those with a mental health condition, 27.6 percent had more than one co-occurrence with another mental health condition. The average Medicaid-first new enrollee with at least one mental health condition cost 15 percent more than the average enrollee without a mental health condition, while Medicare-first enrollees with at least one mental health condition cost 75 percent more than the average enrollee without a mental health condition. These findings establish the scope of the prevalence of mental health conditions among new dual eligible enrollees in Maryland and highlight the need for greater attention and research into this population.
Report in Response to Legislative Request to the Maryland Department of Health and Mental Hygiene to Study the Cost of Providing Access to Managed Care for Medicare+Choice-Eligibles in Maryland Maryland Senate Bill 855, Section 3, 2000 Legislative Session
(Maryland Department of Health and Mental Hygiene, 2001-01-11) Maryland Department of Health and Mental Hygiene

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