Impact of "Institutions for Mental Diseases" Medicaid waivers on opioid use disorder treatment: a mixed methods approach to improve utilization of Medications for Opioid Use Disorders - PROJECT SUMMARY/ABSTRACT: More than 80,000 opioid overdose deaths were reported in the US in 2022. Medication for opioid use disorder (MOUD) significantly reduces the risk of hospitalization and mortality from opioid overdose, but MOUD is severely underutilized. In addition, there are significant geographic, racial, and ethnic disparities in MOUD use. Medicaid is the largest payer of treatment for opioid use disorder (OUD), with the potential to reach a large share of the population in need of treatment. In 2015, state Medicaid programs began to adopt the newly created Section 1115 “Institutions for Mental Diseases” (IMD) waivers. These waivers allow states to use federal funds for substance use treatment in residential facilities. To date, 33 states and the District of Columbia have adopted an IMD waiver. However, it is unclear whether waivers have an impact on MOUD use and retention. State Medicaid programs have broad discretion on services covered for substance use disorders, which may lead to significant variation in treatment across jurisdictions. A careful examination of waiver configurations to compare them across jurisdictions is needed, and this effort will be among the first. This Mentored Research Career Development Award (K01) proposes a community-engaged, mixed methods research to (1) characterize IMD waivers characteristics and provide a detailed description of waiver features in a standardized way that allows for comparison across jurisdictions, (2) quantitatively measure the impact of IMD waivers on MOUD-based treatment and health outcomes (e.g., MOUD initiation, retention, and overdoses) using Medicaid claims, and (3) qualitatively explore waiver implementation in the first 10 jurisdictions that adopted a waiver using in-depth interviews with stakeholders engaged in state Medicaid agencies, provider networks, and advocacy groups. Mixed methods will be used to triangulate findings from the aims and provide a comprehensive picture of the policy. The community-engaged component of this study will include an advisory board to provide ongoing input, including interpretation of results to translate study findings into practical knowledge for policymakers. Findings from this research will characterize persisting and potentially new gaps in access to MOUD that, if addressed, can substantially improve public health and well-being. The training and mentoring plans will build silks and expertise in (1) legal epidemiology methods to code and analyze waiver policies (Aim 1), (2) advanced causal inference methods using real-world Medicaid claims data and content expertise on opioid use disorders treatment to measure the impact of waivers on outcomes at the population level (Aim 2), (3) community-engaged and mixed methods approaches to investigate the implementation of waivers at the local level and to triangulate data from quantitative and qualitative aims guided by the perspective of stakeholders with lived experience. This award will provide a platform to launch an independent research program that will fill a critical gap in knowledge about policies to scale up MOUD use.
