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The role of state governance in the adoption of pharmaceutical technologies in substance abuse treatment

The Role of State Policies in the
Promoting the Adoption of Evidence-
Based Treatments for Substance Abuse

Prepared for Evidence-Based Health Policy Acknowledgements
„ Co-author, Carolyn Hill, and research assistants, Nancy Chan, Katie Keck, Kevin Murphy and CJ Park „ The Robert Wood Johnson Foundation Substance Abuse Policy Research Program for funding „ The University of Wisconsin Graduate Research Fund and the Georgetown Public Policy Institute at Georgetown University for research assistance support Overview
„ Do state policies affect treatment facilities’ „ Focus on naltrexone for alcohol abuse treatment facility- and state-level factors to explain naltrexone adoption „ General Findings: States have policy levers they can exercise to increase use of evidence-based treatments (e.g., naltrexone) Research Motivation
„ High stakes for governments to design effective „ 19 million (8% of U.S. pop) meet standard diagnostic criteria for alcohol use disorder; few seek treatment „ Direct and indirect costs of alcoholism: approx „ States spend $1 of every $7 on substance abuse programs and consequences; less than 5% of this
on prevention, treatment, and research

Naltrexone: Pharmacotherapy for
Alcoholism Treatment

„ Quells cravings for alcohol; dulls “high” feeling „ FDA-approved in 1994; available as generic „ No close therapeutic substitutes; effective alone „ Relatively unrestricted supply; cost-effective
„ Yet prescription rates low (est. 2 to 13%) in
specialty treatment settings; lower rates
among wider population

Clinically-proven, cost-effective
treatments under-utilized: Why?

treatment staff characteristics (education, treatment philosophy), patients’ alcohol cravings/compliance orientation, insurance coverage, managed care participation „ Role for state-level policy factors in „ Medicaid funds and related block grants constitute „ Only 6% diagnosed as alcohol dependent get
medication during treatment; one-third cite cost
or insurance as key barrier

Types of State-Level Variation That
May Affect Treatment

„ State Medicaid policies: setting co-pays, contracting with managed care programs, and imposing prescription limits (e.g., quantity supply/refill limits) „ State agency funding for treatment (for persons not covered by Medicaid or other insurance) and types of services funded „ Managed care/cost containment practices„ Economic and health care capacity conditions Study Data
„ Facility-level measures:
„ 2003 National Survey of Substance Abuse Treatment Services (N-SSATS): all public and private facilities providing treatment in U.S. (96% response rate, n=13,623) „ State-level measures (general categories):
„ Medicaid enrollments and policies/benefits for mental health, rehabilitation services, and prescription drugs; state health care capacity and financing; state general fiscal and economic health, and state population characteristics Naltrexone adoption and state-level policies
% of facilities in state that adopted naltrexone Medicaid benefits for rehab: co-pay required Medicaid benefits for rehab: SA limitations Medicaid prescription drugs coverage limitations-quantity supplied 56% Medicaid prescription drugs-other coverage limitations Medicaid policy: state preferred drug list Medicaid policy: number of refills limited Medicaid policy: generic rate paid for brand Medicaid policy: generics on PDL/formulary Capitated/MCO delivers Medicaid benefits State-level policies and spending
State permits MCO/PCCM to set policies regarding State permits MCO/PCCM to set policies regarding prior State permits MCO/PCCM to set policies encouraging generics State permits MCO/PCCM to set policies restricting access to Substance abuse treatment block grant funding per capita State discretionary funding for substance abuse treatment (per State discretionary funding for substance abuse prevention (per Needing But Not Receiving Treatment for Alcohol Problems in Key Findings from Empirical
Analysis on Role of State Policies

„ Estimates of state policy effects, controlling for „ Facilities more likely to adopt naltrexone in „ Allow MCO/PCCM to set policies encouraging „ Contract with MCO to deliver Medicaid benefits: „ Include generics on preferred drug list/formulary: Key Findings from Empirical Analysis

„ Facilities less likely to adopt naltrexone in „ Contract w/MCO to deliver Medicaid pharm „ Establish a preferred drug list: odds ↓ 21% „ Limit Medicaid benefits for rehabilitation services (for use in substance abuse treatment): odds ↓ 16% Implications of empirical findings
„ No state completely consistent in establishing policies that increase (rather than impede) access to medical treatments „ Wisconsin improving, but still has policies with „ Could further reduce substance abuse treatment limitations, monitor MCOs to ensure access to pharm benefits not restricted, more proactively encourage adoption of proven medical treatments „ California, Florida, Iowa, Maine, Massachusetts and Vermont most actively encourage adoption of naltrexone by explicitly including it on preferred drug list Policy Implications
„ Considerable potential for addressing unmet need for access to a clinically-proven, cost-effective treatment for alcohol abuse/dependence „ <1% of those in need of treatment receive medication to aid „ ~33% needing treatment/recognizing need but not receiving „ $4-7 returned in reduced drug-related crime/criminal justice costs for every $1 invested in treatment; adding health care savings increases ratio of savings/costs to $12:1 „ Deficit Reduction Act of 2005 allowed states greater flexibility for modifying/managing Medicaid programs;
evidence suggests for room and need for improvement


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