Journal of Substance Abuse Treatment xxx (xxxx) xxx

Contents lists available at ScienceDirect

Journal of Substance Abuse Treatment

journal homepage: www.elsevier.com/locate/jsat

Ensuring access to high-quality substance use disorder treatment for

Medicaid enrollees: A qualitative study of diverse
stakeholders’ perspectives
Jenny Zhen-Duan a, b, *, Marie Fukuda a, Melissa DeJonckheere c, Irene Falgas-Bagué a, b,
Steven Miyawaki d, Parwana Khazi e, Margarita Alegría a, b, f
a
Disparities Research Unit, Department of Medicine, Massachusetts General Hospital, Boston, MA, USA
b
Department of Medicine, Harvard Medical School, Boston, MA, USA
c
Department of Family Medicine, University of Michigan, Ann Arbor, MI, USA
d
Department of Sociology, Bowdoin College, Brunswick, ME, USA
e
Department of Public Health, Santa Clara University, Santa Clara, CA, USA
f
Department of Psychiatry, Harvard Medical School, Boston, MA, USA.

A R T I C L E I N F O A B S T R A C T

Keywords: Background: Medicaid programs are vital to ensure low-income individuals have access to substance use disorder
Substance use treatment (SUD) treatment. However, shifts in Medicaid policies may alter coverage and SUD care for this population, who
Policy implementation already face difficulties receiving high-quality SUD treatment. Using a policy implementation research approach,
Medicaid
we sought to identify barriers and facilitators when transitioning from Medicaid fee-for-service to managed care
Managed care
New York
plan structures and opportunities for improving SUD care in New York State (NYS).
Method: Study staff conducted semistructured, in-depth qualitative interviews (N = 40 total) with diverse
stakeholders involved with different aspects of SUD treatment in NYS, including policy leaders (n = 13), clini­
cians (n = 12), Medicaid managed care plan administrators (n = 5), and patients (n = 10).
Results: Findings from thematic analysis centered on three themes: 1) while transitions to managed care have
benefited clinicians, certain policies affect patients' Medicaid enrollment and quality of care; 2) stakeholders
perceived individuals with dual diagnoses, older adults, and linguistic minorities to be at higher risk for inad­
equate care; and 3) current quality metrics may not adequately capture treatment quality.
Conclusion: Policy changes should focus on promoting increased collaboration among stakeholders, expanding
Medicaid coverage, and reducing stigma. Resources should be diverted to facilitate psychiatric care for patients
with dual diagnoses and to build workforce capacity to adequately meet the needs of older adults and linguistic
minorities. Opportunities for NYS Medicaid include adapting performance metrics to capture meaningful patient
outcomes and link reimbursements to improvements in patients' quality of life.

1. Introduction SUD treatment for low-income individuals (Humphreys & Frank, 2014).
However, the shifting policies, landscape, and structure of Medicaid may
In 2017, 19.7 million individuals in the United States battled a affect care for low-income populations, who already face greater bar­
substance use disorder (SUD), amounting to 7.2% of the entire country's riers to quality and adequate SUD treatment (Olfson et al., 2018). High
population aged 12 and older (Substance Abuse and Mental Health quality SUD care includes timely assessment of disease severity, wrap­
Services Administration, 2018). Low-income communities evidence a around services for substance use, physical health, and provision of long-
disproportionately high prevalence of SUDs (Andrabi et al., 2017; term supports (Fields & Roman, 2010). Research can point to how best
Collins, 2016; Karriker-Jaffe, 2013). Medicaid and Medicaid expansions to improve access and deliver high quality SUD treatment.
sponsored by the Affordable Care Act are critical in ensuring access to New York State (NYS) has the second highest prevalence of opioid

* Corresponding author at: Disparities Research Unit, Department of Medicine, Massachusetts General Hospital, 50 Staniford Street, 8th floor, suite 830, Boston,
MA 02114, USA.
E-mail address: [email protected] (J. Zhen-Duan).

https://doi.org/10.1016/j.jsat.2021.108511
Received 2 November 2020; Received in revised form 1 February 2021; Accepted 26 May 2021
Available online 31 May 2021
0740-5472/© 2021 Elsevier Inc. All rights reserved.

Please cite this article as: Jenny Zhen-Duan, Journal of Substance Abuse Treatment, https://doi.org/10.1016/j.jsat.2021.108511
J. Zhen-Duan et al. Journal of Substance Abuse Treatment xxx (xxxx) xxx

use or dependency in the United States (National Survey on Drug Use centers in New York City, asking them for assistance in recruiting pa­
and Health, 2017). The number of overdose deaths among NYS residents tients. Participating clinics then recruited and specified dates and times
tripled between 2010 and 2017, increasing from 5.4 to 16.1 deaths per for in-person interviews. Before recruitment, we estimated needing an
100,000 people (New York State Department of Health, 2019). Begin­ overall sample of 40–50 total interviews to reach valid conclusions
ning in 1997, NYS began to transition most of its Medicaid beneficiaries across stakeholder groups (Guest et al., 2006).
from a traditional fee-for-service system to Medicaid managed care
(Centers for Medicare & Medicaid Services, 2019a), to centralize ser­ 2.2. Procedure
vices and lower overall health care expenditures (Berwick & Hackbarth,
2012; Centers for Medicare & Medicaid Services, 2019). Despite this We conducted semistructured, in-depth interviews, a qualitative data
change, coverage for behavioral health services remained limited for collection technique that uses an interview guide while allowing flexi­
more than a decade (Centers for Medicare & Medicaid Services, 2019a). bility for interviewers to ask additional questions and elicit new topics
In 2011, NYS launched a Medicaid redesign project that carved out (DeJonckheere & Vaughn, 2019). The research team developed inter­
behavioral health services previously excluded from managed care plans view guides using an iterative process and tailored them to ask each
(New York State Department of Health, 2011). While this change diverse stakeholder group about the same domains. Final interview
allowed for more insurance coverage among low-income individuals, guides focused on (1) general barriers and facilitators to receiving or
the rates of SUD treatment remained the same (Olfson et al., 2018). providing SUD quality care, (2) differences in SUD services received or
Implementation of parity laws that allow equal coverage of behavioral offered from Medicaid fee-for-service in contrast to managed care, (3)
and physical health have been posited as primarily Medicaid's re­ and evaluation of SUD quality of care. PhD researchers trained in con­
sponsibility (Geissler & Evans, 2020). However, Medicaid managed care ducting qualitative interviews conducted all interviews. The study team
organizations (MCOs) continue to face challenges in the provision of interviewed patients in person, while we interviewed other stakeholders
behavioral health coverage and care integration (Tuck & Smith, 2019). via phone. Interviews lasted 30 to 60 min, averaging around 45 min.
Most notably, MCOs report CFR 42 regulations as a primary barrier, Study staff obtained verbal consent, or written consent for patients, to
since limitations on information sharing hinder interinstitutional care participate in the study and be audio-recorded. Study staff conducted all
coordination for SUD treatment (Tuck & Smith, 2019). Other docu­ patient interviews in private rooms at the clinics. All participants
mented barriers to accessing quality SUD care for Medicaid enrollees received a $100 gift card for their participation, although most policy
include treatment center norms and providers' biased attitudes (Foney & leaders declined compensation because of payment restrictions associ­
Shannon Mace, 2019). Thus, managed care plans, policy-makers, and ated with their agencies. The Partners Healthcare Institutional Review
clinicians hold critical roles for increasing access to quality SUD care for Board approved the study.
Medicaid enrollees.
Existing administrative data are useful in assessing the performance 2.3. Analysis
of Medicaid MCOs, but they tend to be incomplete (Pawlson et al.,
2007). While administrative data may identify problems, they cannot Research staff transcribed the interviews verbatim, and de-identified
elaborate on policies and practices that cause these problems or their and imported them into Dedoose, an online application for qualitative
potential solutions (McGinnis et al., 2014). The goal of policy imple­ data management and analysis (Dedoose, 2020). This study used a
mentation research is to understand factors that influence the trans­ thematic analysis framework, consisting of the following stages: famil­
lation of policies (e.g., rules, laws, and regulations) into practice, as iarization with the data, creating codes, coding transcripts, generating
many of the greatest health advances have been attributed to successful and reviewing themes, and describing and finalizing themes (Braun &
policy change and implementation (Nilsen et al., 2013). Using a policy Clarke, 2006). As we collected data, the research team met regularly to
implementation research approach (Nilsen et al., 2013), we sought to review and discuss ongoing interviews and become familiar with the
engage different stakeholders to identify the effects on SUD care when data. Next, the team developed an initial code book, and two trained
transitioning from Medicaid fee-for-service to managed care, and the coders (PK & SM), coded transcripts independently, identified coding
outstanding barriers and facilitators to receiving or providing SUD differences, and met with the larger team to discuss discrepancies and
quality care through managed plan structures. We used a qualitative suggest codebook modifications. The team iteratively refined the code­
approach to gather the perspectives of different stakeholders to under­ book through this process until the team developed a final codebook.
stand barriers and facilitators that influence policy implementation The two coders coded all interviews independently, reviewed discrep­
(Head & Alford, 2015). ancies between themselves until they reached consensus (Corbin &
Strauss, 2014), and the first author (JZD) confirmed their codes. We
2. Method grouped patterns of responses generated from codes into potential
themes across stakeholder groups (Braun & Clarke, 2006). Refinement
2.1. Participants and recruitment and clarification of themes occurred collaboratively among research
team members until we solidified these themes and excerpts.
The Disparities Research Unit at Massachusetts General Hospital in
Boston coordinated this research. We designed purposeful sampling to 3. Results
recruit diverse types of “information rich” (Patton, 2002) stakeholders:
policy leaders, including state-level employees, leaders within advocacy 3.1. Sample and study overview
organizations, or academics focused on SUD research and policy; clini­
cians or clinic administrators who provided SUD treatment services Of the 88 stakeholders invited, 40 agreed to participate, including
(herein referred as clinicians); plan administrators working within SUD policy leaders (n = 13), clinicians (n = 12), plan administrators (n = 5),
care in Medicaid MCOs; and patients receiving SUD treatment through and patients (n = 10; see Table 1 for demographic information). Refusals
Medicaid. Recruitment started with seven policy leaders who had agreed came mostly from plan administrators and clinicians who did not have
to participate in connection with this research. The study recruited interest or clearance to participate.
additional participants through snowball sampling techniques, where Policy leaders, plan administrators, and clinicians varied in locality
policy leaders referred us to plan administrators and/or clinicians. (rural, urban). Most clinicians worked in outpatient settings, and 10
Concurrently, we used NYS listings of Medicaid substance use plans and reported that their clinics offered medication for addiction treatment. Of
providers to contact additional participants. For patient recruitment, the clinicians, six worked in community outpatient/inpatient treatment
research team contacted state-listed SUD treatment and harm-reduction centers, four participants were linked with university hospitals/hospital

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J. Zhen-Duan et al. Journal of Substance Abuse Treatment xxx (xxxx) xxx

Table 1
Participant information for individual interviews (N = 40).
# of Participants Male Female Mean Age (SD) Race Ethnicity

Patients 10 7 3 40.8 4 Latino

(range 27–65) 3 White; 1 Black; 2 Asian
Plan administrators 5 5 0 62.0 5 White
(range 41–74)
Cliniciansa 12 4 6 54.7 1 Latino
(range 46–58) 6 White; 4 Black; 1 Asian
Policy leadersb 13 4 6 52.7 7 White; 1 Asian 2 Latino
(range 34–61)
a
Two clinicians missing gender.
b
Three policy leaders missing demographic data.

clinics, one worked in private practice, and one worked within a forensic One clinician described the utility and breadth of clinical audits,
setting. Four of these clinicians worked for clinics providing methadone explaining that MCOs:
treatments, three mentioned provision of naltrexone, Vivitrol, and
call our main headquarters and say ‘Hey, you billed us for [name] on
buprenorphine within their care settings, and one described care based
[date]’ and that note has to be produced, what they look for is the
on an abstinence model. About half of patients were mandated to receive
quality care within the note, what specific therapy was used. Did you
treatment.
use MI [motivational interviewing], did you use CBT [cognitive
Based on the qualitative interviews, the research team identified
behavioral therapy], reality therapy, what was used, is it docu­
three major themes: 1) while transitions to managed care have
mented appropriately, is it a billable note as per the APG [Ambula­
benefitted clinicians, certain policies affect patients' Medicaid enroll­
tory Patient Groups] guidelines. So, it's very, very specific.” (P30,
ment and quality of care; 2) individuals with dual diagnoses, older
Clinician).
adults, and linguistic minorities were perceived to be at higher risk for
poor quality care; and 3) current Medicaid quality metrics may not Clinicians and plan administrators believed that these audits were
adequately capture treatment quality. Themes presented here represent important to establish accountability and ensure that clinicians provided
common experiences across multiple stakeholder interviews and are quality care. Increased accountability also meant that clinicians were
accompanied by illustrative quotations. We present additional sup­ responsible for providing quality of care and producing proper docu­
porting quotes in Table 2. mentation to be reimbursed for services:

If you're not meeting the quality of care that's supposed to be pro­

3.2. Theme 1: while transitions to managed care have benefitted vided, or your documentation is not correlating with the services that
clinicians, certain policies affect patients' Medicaid enrollment and quality were billed, you lose money on that. They're [MCOs] very strict on
of care that.” (P30, Clinician).

Policy changes in the past decades have allowed for easier access to
SUD treatment for Medicaid enrollees, but certain policies continue to 3.2.2. Certain Medicaid policies exacerbate problems with healthcare
hinder quality of SUD care. Three subthemes emerged: (1) Managed care navigation and enrollment
provides accountability and support to providers, (2) certain Medicaid All patients in this study acknowledged that they would not have
policies exacerbate problems with health care navigation and enroll­ been able to receive care without Medicaid due to costs, particularly in
ment, and (3) unintended consequences occur with some policies crafted inpatient settings. However, some patients stated they liked the “old
to improve SUD care. Medicaid” better because they could go to any clinic that accepted
Medicaid without restrictions. One of the biggest barriers for patients
3.2.1. Managed care provides accountability and support to providers following the transition to MCOs was not understanding the constraints
Participants believed certain aspects of managed care were critical to of managed care:
improving SUD access for Medicaid beneficiaries. One participant stated Patients don't really understand managed care. They don't under­
“…with managed care, there's more oversight, accountability, and stand why they can't go to Dr. V anymore and they have to go to Dr. S,
ability from the managed care plans to contact a provider or nudge the because Dr. V is not in that HMO [health maintenance organization]
provider on things.”(P14, Plan administrator). Stakeholders described … The patient then changes to [MCO] but doesn't understand that
Medicaid as an exceptional resource for people seeking SUD treatment there's a waiting period to go to [MCO], so they have to wait to see
and that managed cared structures have allowed for more opportunities the doctor. So, in the meantime they'll go to the emergency room.
to provide accountability and support, and thus improved quality of care (P23, Clinician).
provided: “Medicaid seems to be the gold card here.” (P29, Clinician).
This experience was particularly salient among patients, who valued All stakeholder groups acknowledged the negative impact of MCOs
access to Medicaid: on patients' preferences for care, including SUD care.
Stakeholders described that certain related policies can hinder
Interviewer: “What do you think that we as providers, as society, enrollment and therefore affect SUD care. For example, patients often
should do to make sure that people get the services they need?” relied on public assistance, which can be revoked if patients do not
P34, Patient: “Give them Medicaid.” (Laughs) follow through on mandated treatment. One patient described some of
the practical barriers outside of Medicaid that can affect SUD care for
Clinicians and plan administrators largely favored the transition Medicaid beneficiaries:
from fee-for-service to managed care, particularly because MCOs pro­
vided oversight and support to providers, and included MCOs' clinical If you don't go to the appointments… the person that's giving you the
audits: “Managed care audits are different from [state] audits because Medicaid will… shut you[r public assistance] down real quick. You
they focus more on clinic-issues and it's created a whole other level of don't know why they didn't go to the appointment. You don't [know
accountability and work to be done” (P21, Clinician). if they] have received it in the mail. Not only that, but they tell you

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J. Zhen-Duan et al. Journal of Substance Abuse Treatment xxx (xxxx) xxx

Table 2 Table 2 (continued )

Additional illustrative quotes. Theme 2: Individuals with dual diagnoses, older adults, and linguistic minorities were
Theme 1: While transitions to managed care have benefitted clinicians, certain perceived to be at higher risk for poor quality care
policies affect patients' Medicaid enrollment and quality of care
Sub-theme Representative quote(s)
Sub-theme Representative quote(s)
Sub-theme Representative quote(s)
Managed care provides accountability “I think there's better care coordination,
Dual diagnoses “for instance, somebody getting buprenorphine maintenance in
and support to providers at least potentially, with the managed
primary care who has a primary psychiatric disorder- we still
care patients versus fee-for-service,
struggle to tie them into our behavioral health services in
which I think is going to be key if you're
addition to the primary care-… they will often be evaluated by
looking at what needs to be done
general psychiatry and told they need specialty addiction
regarding substance use disorder. I think
treatment, which they're already kind of getting, but not in the
a lot is haphazard under fee-for-service
sense of a traditional outpatient program, and so they may
and I think there's a lot that can be gained
essentially be refused entry into a general mental health clinic
with better care coordination.” (P19,
for say, management of their bipolar disorder, because the
Plan administrator).
mental health clinic has the kind of triage algorithm that puts
“So [with managed care], every client
people with active substance use disorders over in intensive
has an individualized treatment plan and
outpatient treatment where they can get psychiatric services and
we try very hard to make sure that the
addiction treatment, including buprenorphine, but [where] that
needs of the individual is met so that we
person's already on buprenorphine in their primary care, they're
can provide good quality care.“(P30,
not gonna stop doing that, they're not looking for an intensive
Clinician).
outpatient program, and the result is, 3 to 6 months later, the
“…with managed care, some of the
person still doesn't have a psychiatrist.” (P22, Clinician)
restrictions about seeing more than one
Older adults “say for instance, a[n older] patient who comes in a day early, or
provider in a day has been lifted. So folks
two days earlier, they don't have any medication, and then it's in
can more conveniently access things at
the computer that they were issued medication for those two
times, or have a psychiatry appointment
days, what happened is one of the policy in the clinic is that if
and another provider appointment, and I
they don't return that bottle then they're supposed to not get any
think that has, where that can happen,
more take home until their case has been discussed in a
that is helpful, and in the traditional
disciplinary meeting. So then, we, the medical directors,
Medicaid system that was always
sometimes they have to decide that they have to give that,
challenging.” (P11, Policy leader)
depending on the medical situation with that person, that they
Certain Medicaid policies exacerbate “I was already in treatment. So, they
will have to document that this policy cannot be applied to this
problems with healthcare navigation [Medicaid] were asking me for proof of
person. You know, which can be a little tricky, because it's there
and enrollment address, if I was taking money and proof
as a guideline, so these are things that I think OASAS needs to
of the program. So, I came and told
look at, revise in their policy, to ensure that we are not being too
[name of clinician] ‘Hey, they are asking
hard on the population that's aging and having these
me for proof of the program,’ so she
difficulties.” (P18, Clinician)
made me the letter. Then I brought the
“…that aging population is absolutely being affected. We don't
letter to them [Medicaid] and finally I
discharge them. I take a financial loss, I'll tell you that right now
have it [insurance]. [I lost insurance for]
(laughs) and we just do a sliding fee scale for those who can
about two weeks” (P37, Patient)
afford it, for those who can't, we're just carrying them. It's unfair
There are unintended consequences of “one of the issues that I have with how
for someone who's had treatment for 30 years to all of a sudden
some policies crafted to improve SUD the state has set that up is in order for
tell them you can't receive services here [when aged out of
care practitioners to bill for SBIRT (Screening,
Medicaid]. So those are the main barriers, is the patient needing
Brief Intervention and Referral to
education and then our aging population not getting the services
Treatment), they have to take a 4-h
they need as a result of not having Medicaid.” (P23, Clinician)
continuing education course about that,
Linguistic “…it's not always easy to find the facility you need. I've got a
which, it's 4 h to do that when in order to
minorities fairly large population of Orthodox Jews. They only speak
prescribe opioids, we have to have a 3-h
Yiddish. I have Yiddish [speaking] counselors but I don't always
course. There's something wrong with
have enough and I can't always get them in.” (P20, Plan
this” (P19, Plan administrator)
administrator)
“I don't care if someone stays 10 days, 20
days, 30 days, or 40 days, if they need to
be there. And if you're working a Theme 3: Current Medicaid quality metrics may not adequately capture treatment
transition that makes sense. If you are quality
focusing, which is what the state is doing
with the regulation, on time, you're not Sub-theme Representative quote(s)
focusing on quality of care. You can't do Utility of quality metrics and “I think that Medicaid data itself, the
both.” (P20, Plan administrator) assessments records that you have now, I think would
“[When selecting SUD care options for not allow any kind of analysis about
enrollees] You're reduced to these patient experience. There would just be a
programs that are insurance-driven lot of assumptions of – it looked like this
models that are going to be like ‘We'll get patient or this person was continuing with
you in for two and half minutes and then care, and then all of a sudden they
we'll throw you out and we'll put you into stopped. We don't know what that means,
an IOP [intensive outpatient program] right? Does it mean they were disenrolled,
and we'll see you for six times, and then or does it mean they moved, you know, it's
we're gonna move you down a level and really hard to know what that means..”
move you down a level, and then we're (P6, Policy leader)
going to declare you well in 6 to 12 Quality measures lack patients' voices “DOH [Department of Health] knows
months, then you have no contact and what they do, and OMH [Office of Mental
that's it. Goodbye! If you're left!” (P13, Health] knows what they do, but no-one is
Clinician) looking at the patient, they're looking at
the system. And we don't know how a
patient who has a disease that is affected
Theme 2: Individuals with dual diagnoses, older adults, and linguistic minorities were
by all these elements can navigate all
perceived to be at higher risk for poor quality care
these systems.” (P1, Policy leader)
(continued on next page)

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J. Zhen-Duan et al. Journal of Substance Abuse Treatment xxx (xxxx) xxx

Table 2 (continued ) are they doing? They're avoiding medical care at all costs” (P23, Clini­
Theme 3: Current Medicaid quality metrics may not adequately capture treatment cian). However, most clinicians described working around coverage
quality regulations by providing services on a sliding scale, reserving funding
Sub-theme Representative quote(s)
for the uninsured (“a little pot of gold,” P30, Clinician), or providing free
services to ensure SUD treatment was continuously offered. While policy
Quality of SUD care should include “as a social worker, that's just something
leaders explained that NYS reimburses treatment for uninsured in­
measures for individuals' daily and that is innately within me as far as
social functioning understanding how culture, how a dividuals, front-line providers in this study did not seem aware of this
socioeconomic background, how coverage or could not access it.
education, how environment, how all
these things affect an individual and how 3.2.3. Some policies crafted to improve SUD care have unintended
we can't put, it's not a one, as they say,
cookie-cut treatment. You know, like one
consequences
way does not work for everyone.” (P17, One NYS regulation that was often mentioned among plan admin­
Clinician) istrators and clinicians was utilization management, a process whereby
“I think if we could measure and capture plan administrators assess the appropriateness of the care provided (e.g.,
the length of a person's recovery further
prior authorizations). NYS prohibits plans from performing utilization
out, you know, how they are doing a year
from now, and if we could even measure management or denying coverage for the first 14 days of inpatient
their quality of recovery, and I think that treatment; this policy elicited mixed reactions among stakeholders. For
gets back to some of their other health example, one plan administrator believed that prohibiting plans from
needs, you know, work, the family utilization management was detrimental as plan administrators could
connections, their physical health, you
know, they made their initial primary
not help members to choose the best course of treatment:
care appointment very shortly after we
Because we see people who get admitted to facilities over and over.
discharged them and a health issue was
identified and then they maintained their We reach out to the facility and say ‘We want to help you manage the
connection with that primary care transition because this guy's flunking transition, time after time after
physician to address that health issue, time.’ And the facilities say to you ‘Hey, the law says I don't have to
which then improves their quality of life,
talk to you for 14 days.’ So what you get is a managed care expert
their quality of recovery. Those would be
very very helpful measurements, that I
who has a network and has the ability to really help with transitions
think that would then, and family of care, engaging with a provider who says ‘I don't need to talk to
connections- did we do a good job with you, I'll do it myself’ but they don't do it, and we're not allowed to
the family treatment program? Do we touch them… If you create wedges between managed care and the
need to improve on that based upon the
provider community, the person who gets ripped apart and falls in
connection that people make with their
family, work, do we need to do more with the hole that's created is the member. (P20, Plan administrator).
vocational training?” (P25, Clinician)
However, clinicians and policy leaders viewed the prohibition of
utilization management as necessary to protect patients' rights to acute
that [you have to go] face-to-face with the HRA [Human Resources treatment. Some clinicians perceived difficulties getting MCOs to
Administration]. How you gonna go to HRA if you don't have reimburse inpatient stays, which created serious disruptions to clinical
Medicaid or Metrocard? (P34, Patient). care:

Outpatient clinicians helped uninsured individuals to enroll in Utilization management says “this guy keeps going to rehab or to
Medicaid, yet one policy leader who also performs clinical duties inpatient, something's wrong,” so we already determined that he
explained that “Medicaid has a 45-day waiting period” before benefits needs a higher level of care, and [plans say] “he can only stay for 10
are in place so providers may offer treatment but are not guaranteed days,” and we're like, “Noooooo! He needs to be at least through the
reimbursement: 28th to get him out of the environment, away from the places,
people, and things that are causing these problems and then he can
While they may be in our treatment program, we're not getting start to heal.” So that's a big thing because of not enough time being
reimbursed, and if they leave treatment early, we don't get reim­ okayed for these managed cares. (P29, Clinician).
bursed at all, and they're not connected. Because they left treatment
so they lose their benefits. So that's a bureaucratic function—that's The study did not specifically ask participants about utilization
really what it is, it's a processing and a bureaucratic function.” (P25, management and patients did not speak to the implementation and
Policy leader). effectiveness of this policy. However, many talked about the impact that
“treatment leverage” policies had on their lives. Treatment leverages
Participants also reported that Medicaid enrollees experienced lapses included mandated treatment to avoid incarceration or regain custody
in coverage due to income fluctuations that impacted their eligibility of their children, the latter being particularly salient among female
and SUD care: patients. Some patients, clinicians, and plan administrators perceived
People fall in and out of enrollment… I think [it] speaks to a very these leverages as punitive rather than focused on their healing process.
vulnerable population whose care is going to be compromised Here some patients describe their experiences with mandated treatment
because, if their income changes modestly, then they might not be and ways that it influenced their perception of quality of SUD care:
eligible for several months. Lapses in being actually enrolled in [Treatment centers would say] “You're doing this, you're doing that,
Medicaid might in and of itself be a marker of poor quality of care.” you're not complying” and then they'd go back to the court and say
(P6, Policy leader). this and this and that, and then the ACS worker will say “Oh yes, she's
Stakeholders across groups described how policies can leave people not complying and she doesn't want her kids.” No, that's not it. You're
without insurance coverage or treatment, hindering quality of SUD care. putting me in a place that I'm not comfortable with, that I don't feel
Describing patients who lose SUD coverage in the transition from like I'm getting what I need. But they don't care about that, they just
Medicaid to Medicare, one clinician states: “they're afraid to go to want you to go to the program and complete what you've got to do.
emergency rooms because they know they're going to get a bill. So what (P31, Patient).

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J. Zhen-Duan et al. Journal of Substance Abuse Treatment xxx (xxxx) xxx

I came on my own this time around, and it works. When you're missing “methadone appointments” by going at the wrong times due to
mandated, it seems like you're doing it for something, you know, you cognitive decline and that some had chronic conditions (e.g., chronic
want to stay clean because you're going to get in trouble or go back to pain) that were compounded by withdrawal symptoms. Patients
jail, lose your kids, lose your apartment, lose whatever the man­ explained that SUD treatment was rarely tailored to older adults and
dation was about. I'm doing this on my own now, and I feel good noted their older peers' difficulties to remain in care. One policy leader
about it. (P34, Patient) explained: “I think older adults get short shrift in the treatment com­
munity, and we don't have tailored programs that meet their needs and
Thus, while some patients found mandated treatment helpful, most
don't necessarily look into or address the issue of physical co-morbidities
believed that treatment leverages did not help them to stay engaged in
in that population” (P11, Policy leader).
treatment. Many programs have strict requirements for daily check-ins
as a condition of receiving medication, with consequences for missing
3.3.3. Linguistic minorities
visits including inability to see their families. Patients described that
Participants also described care challenges for linguistic minorities
these leverages exacerbated the stigma, shame, and punitive nature of
as a result of language barriers. For example, one clinician talked about
SUD treatment, hindered their ability to stay engaged, and therefore
patients they see more intensively in their outpatient clinic because of
reduced the perceived quality of SUD care.
language barriers:

[these patients] need a high level of service, which means they are
3.3. Theme 2: stakeholder perceived individuals with dual diagnoses, not really meeting the criteria of outpatient, but because of their
older adults, and linguistic minorities to be at higher risk for inadequate language barriers there is no residential or inpatient provider
care available for people who do not speak English. (P24, Clinician).

Participants described that the transition to managed care improved Despite making accommodations, resulting care could still be
access to SUD treatment in general and that most patients could readily insufficient to meet patients' needs. Evidence-based treatment, such as
access most SUD treatments if they wanted. However, policies tran­ peer advocacy trainings, was sometimes unavailable to linguistic mi­
sitioning to managed care practices failed to address disparities in care norities, despite stakeholders' acknowledgement of the importance of
for some groups, which included individuals with (1) dual diagnoses, (2) peer advocacy in recovery. Per participants, despite the linguistic di­
older adults, and (3) linguistic minorities. versity in NYS, language barriers were particularly salient for those
whose primary language was less common (e.g., Arabic, Chinese,
3.3.1. Dual diagnoses French).
Clinicians and policy leaders often described that individuals with
dual diagnoses of SUD and severe psychiatric illness were likely to
3.4. Theme 3: current Medicaid quality metrics may not adequately
receive inadequate care despite policy transitions aimed at improving capture treatment quality
access and quality of care. Some stakeholders stated that the disparity
resulted from the lack of centers equipped to adequately address dual Participants discussed ways that quality care was determined and
diagnoses, which had not changed much despite multiple policies assessed in SUD treatment following the transition to MCOs. Three
enacted to improve SUD care: subthemes emerged: (1) the utility of quality metrics and assessments;
We need [to do] more to address the patients with severe mental (2) quality measures lack patients' voices; and (3) quality of SUD care
health … they come here [to the SUD outpatient clinic, and] we end should include measures for individuals' daily and social functioning.
up sending them back to the shelter that they came from … but after
we've tried all the places that we know [that treat dual diagnoses] 3.4.1. Utility of quality metrics and assessments
and people saying ‘no, no no no,’ we end up sending [them] back. Participants (policy leaders, administrators, and clinicians) reported
(P16, Clinician). the multiple quality metrics and assessments that they utilized. Partic­
ipants explained that Medicaid in NYS evaluates SUD quality by tracking
Policy leaders and clinicians explained that patients with dual di­ “service utilization, follow-up after hospitalization, detoxification ser­
agnoses, in particular, have poorer treatment quality because “only vices” and other claims data. The state tracked claims data but also
10%” of psychiatrists accept Medicaid in NYS” and because of the required licensed providers to report patient outcomes data to track
burden placed on patients to attain psychiatric care: clinicians' performance, whereas clinics often had their own internal
quality assessments measures (e.g., patient satisfaction surveys, clini­
One thing that I think has been a long-standing difficulty for all types
cian evaluations). Stakeholders viewed the utility quality metrics
of patients, is accessing psychiatry in an efficient, low barrier way
differently by the role they had. For instance, policy leaders were
that doesn't involve huge commitments. (P22, Clinician).
interested in initiatives and practices to improve statewide care and
Lack of psychiatrists and shortages of prescribers to provide medi­ explained that indicators were intended to assess quality and to
cation for opioid use disorder treatment was also problematic for the “pinpoint how well the services are utilized, and to some extent, how
larger SUD community in general: well are people” (P6, Policy leader). Clinicians had to comply with state-
mandated requirements by reporting indicators intended to demonstrate
While it is very easy to get into a traditional medication-assisted
they were providing good care. However, clinicians were skeptical that
treatment program where you can be prescribed methadone, it is
the data reported to the state related to patient progress or outcomes:
not that simple to find a doctor that can induce you on buprenor­
phine or Suboxone. [Places are] booked 6, 8, 10 weeks out in the You know, outcome measures in substance abuse treatment are very
future, and if someone wants to come off heroin and get on Suboxone crude, and are not really excellent measures of progress in treatment
they can't wait 6, 8, or 10 weeks. (P21, Clinician). or the health of the patient even, and counselors know that intui­
tively and so sometimes they kind of resent it, you're ordering me to
do this or that with an eye toward value based payment for the state,
3.3.2. Older adults
and that doesn't really help my patient at all, or me, or even really
Certain stakeholders also believed that older adults were more likely
measure the progress that they made. (P21, Clinician).
to receive inadequate SUD care, unlike those in other age groups. For
example, some patients shared observations that older adults were Plan administrators approached state quality metrics in ways that

6
J. Zhen-Duan et al. Journal of Substance Abuse Treatment xxx (xxxx) xxx

ensured that they were achieving high quality ratings and remained 4. Discussion
competitive as a managed care organization: “[Managed care organi­
zations are] competing on quality ratings, they're competing on network The current study examined diverse stakeholders' perspectives on
… but they are trying to basically maximize their overall profitability” factors related to access to quality of SUD care for those insured through
(P4, Plan administrator). NYS Medicaid. The study team conducted semistructured interviews and
However, most stakeholders questioned the validity of claims data identified three themes. First, while transitions to managed care have
metrics because they failed to capture the full story: “are we seeing low benefitted clinicians, certain policies affect patients' Medicaid enroll­
rates of utilization because there are no providers or is it because there ment and quality of care. Second, three groups were believed to be at
are providers but for some reason, people are not utilizing [them]?” (P6, high risk for inadequate treatment, including those with dual diagnoses,
Policy leader). Instead, most clinicians and some plan administrators older adults, and linguistic minorities. Third, current Medicaid quality
advocated for metrics that were actionable and could be used to improve metrics may not adequately capture SUD treatment quality.
services. Medicaid remains critical to ensure that low-income communities
receive SUD services (Olfson et al., 2018), as participants described the
3.4.2. Quality measures lack patients' voices relatively accessible and adequate services available through outpatient
Despite some stakeholders' use of state quality metrics to evaluate care. Medicaid expansions and transitions to managed care have allowed
themselves, one common concern expressed across stakeholder groups for more comprehensive and high-quality SUD services through benefits
was that patients' voices were not included in developing quality met­ expansions (Grogan et al., 2016). MCOs are well-positioned to better
rics. For instance, one policy leader said: “When you look at the data allocate resources to avoid excessive health care expenses and oversee
collection system, it's about what we found about the patients, it's never staffing and accountability to ensure high quality SUD care. However,
about what the patient wants” (P1, Policy leader). Stakeholders saw the enrollment gaps hinder access to care, interfere with medication
need to incorporate patient voices and experiences as significant for adherence, and are more likely to lead to hospitalization (Mojtabai,
crafting metric evaluations of quality SUD and decision making: 2019; Tarazi et al., 2017). Our findings are consistent with existing
literature that identifies insurance lapses due to patient income fluctu­
It was really interesting to me one day, sitting in a room with all of
ations as a significant barrier to SUD care (Maclean et al., 2019).
these leaders in the community, and the question was ‘How come
Research has proposed extending eligibility 12 months after initial
people with Medicaid, high risk people on Medicaid, keep on going
enrollment as a way to avoid insurance lapses, balance health care ex­
to the ER for services they don't need to go to the ER for?’ And you
penditures, and improve health of beneficiaries (Swartz et al., 2015).
have all these people who, none of us have Medicaid, right? None of
However, even though NYS became the first to adopt Medicaid eligi­
us are fitting the demographic, and I'm like ‘why can't we ask
bility extensions (Brooks et al., 2015), more research is necessary to
someone who's doing that? (P28, Policy leader).
understand why Medicaid disenrollment remains a barrier and why
To bridge the gap in Medicaid state metrics and provide patient- front-line providers might not be receiving NYS funds intended to cover
centered care, clinicians in this study attempted to make treatment uninsured SUD care for those in coverage transition.
more accessible for patients, often making internal changes to care based Stakeholders had mixed opinions about utility of some SUD treat­
on patients' feedback. Inclusion of patients' experiences in their assess­ ment policies and regulations crafted to improve SUD care. A critical
ments were intended to help move them away from outcome measures, component of successful policy implementation is examining where
such as hospitalizations, and toward more process-oriented data to diverse stakeholders' needs overlap and diverge to address gaps (Dam­
inform immediate changes that clinicians can make within their orga­ schroder & Hagedorn, 2011; Greenhalgh et al., 2004). Whereas clini­
nizations, such as getting feedback on how to make visits more cians and policy-makers believed that prohibiting utilization
convenient. management ensured emergency treatment access, plan administrators
described it hindering successful transitions to outpatient care and
3.4.3. Quality of SUD care should include measures for individuals' daily patient-centered treatment. Lack of communication and coordination
and social functioning between stakeholders appears evident throughout the care continuum,
Policy leaders and clinicians alike wanted to incorporate social needs which remains a barrier to improving SUD treatment and merits prior­
information and functioning levels as foundational SUD treatment itization (Kehn et al., 2015).
quality measures, in particular, with securing and tracking housing in­ Treatment that is leveraged or mandated has been posited as an
formation. One clinician explained: efficient component of treatment for SUD recovery (Wild et al., 2012).
However, these leverages are not associated with greater adherence to
it's not something that we're accustomed to tracking because again SUD care and patients can perceive them as coercive and punitive
our focus has been the substance use and getting that stabilized, but (Redlich et al., 2006). Mandated treatment can be stigmatizing if pun­
because of the homelessness issue and residents in shelters or tran­ ishment is embedded in the broader way SUD care is structured, as
sient living family member living with friends, we've started talking patients in this study described. Policies and clinical guidelines that
about how we can possibly measure that [housing] given the impact encourage the shifting of the philosophy of SUD care toward chronic
that it has on their substance use. (P23, Clinician). disease management models (McLellan et al., 2014) and move away
from acute episodic treatment should be implemented across managed
Clinicians and policy leaders expressed difficulties with knowing
whether SUD care was being optimally evaluated when outcome mea­ care plans serving Medicaid enrollees. Changing overarching treatment
models should include embedding addiction education and treatment in
sures failed to capture how patients were functioning: “[We need to
track] how they return to the workforce, and can maintain a job, have a general medical training (Haack & Adger Jr, 2002), and prioritizing
training to reduce provider stigma of patients with SUDs (Livingston
good relationship/reunion with a family member, [if] they have more
social leisure activities compared with before they came for treatment” et al., 2012). Only by shifting SUD care policies can we address provider
shortages, lessen bias, and implement a whole-person approach to
(P24, Clinician).
Patients echoed this sentiment. Besides feeling welcomed and safe, achieve high-quality care (Skidmore & Budd, 2017).
patients generally regarded high quality treatment according to how Participants in our study perceived SUD care to be inadequate for
well they functioned in daily activities, such as maintaining a job, patients with dual diagnoses, older adults, and linguistic minorities,
resuming activities they enjoyed, and reconnecting with family and echoing previous findings (Antai-Otong et al., 2016; Guerrero et al.,
friends. 2013; Wu & Blazer, 2011). The dearth of treatment centers to address
comorbid SUD and severe psychiatric illnesses was presented as the

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J. Zhen-Duan et al. Journal of Substance Abuse Treatment xxx (xxxx) xxx

main barrier for those dually diagnosed. Our findings are consistent with focusing on specific substances or treatments, which would have
existing literature that identifies the lack of treatment centers for dual allowed for more targeted responses than we could obtain. Our pur­
diagnoses as a persistent problem in SUD care (Antai-Otong et al., 2016). poseful sampling recruitment approach resulted in patient participants
Therefore, expanding centers and building on personnel capacity to only from New York City clinics, thus our patients' experiences may not
work with dual diagnosis remains crucial, particularly as limited treat­ be reflective of patients' experiences in NYS broadly. Stratified sampling
ment centers in the United States are equipped to adequately treat them techniques could help to more explicitly compare the experiences of
(McGovern et al., 2014). Research has shown certified community stakeholders in diverse settings and evaluate the breadth of these find­
behavioral health centers to be a promising solution to increase access to ings. Finally, we had difficulty recruiting plan administrators for this
SUD care for people with comorbid mental health and substance use study. Additional research should help us to further understand the
issues (Kicker et al., 2018). Treatment expansions into different settings differences among stakeholder groups. Despite these limitations, our
(e.g., integrated in primary care, community behavioral health centers) study provides vital data for improvements on access and quality SUD
and through varied modes of service delivery (e.g., telehealth) may also care and opportunities for meaningful practice and policy changes.
allow for low-barrier psychiatric services (Urada et al., 2014) to benefit
patients with dual diagnosis and ease medication access barriers out­ 5. Conclusion
lined by participants. Recent SAMHSA amendments to the CFR 42 reg­
ulations allowing facilities to engage in more information sharing may Policies implemented in the past decade have facilitated compre­
improve quality of SUD care (U.S. Department of Health & Human hensive SUD services for low-income and vulnerable patients on
Services, 2020) by facilitating better care coordination by MCOs (Tuck Medicaid. Policy changes that allow for more collaborations among
& Smith, 2019). However, insufficient availability of personnel to pro­ stakeholders, extend Medicaid coverage, and reduce stigmatizing care
vide pharmacotherapy, regarded as critical for guideline concordant are still needed. Resources should be diverted toward facilitating psy­
care for people with SUDs, remains a challenge (Kermack et al., 2017). chiatric care for patients with dual diagnoses, and building capacity to
Stakeholders in this study perceived that SUD treatment was inade­ work with older adults and linguistic minorities. Opportunities for NYS
quate for older adults and linguistic minorities given the scarcity of include tracking meaningful outcomes for patients (e.g., improvement in
tailored treatments and resources for both populations. Older adults quality of life and social needs), and making insurance reimbursement
with opioid use disorders are more commonly treated with methadone contingent upon improvement in patients' quality of life. Future research
than their younger counterparts, increasing the need for monitoring and, could examine stakeholders' perspectives on these proposed solutions,
subsequently, the risk for inadequate adherence (Harris et al., 2005; including how to balance the need for quality SUD care with the
Neighbors et al., 2019). Researchers and practitioners should consider extensive related costs.
efforts to increase case management programs tailored to older adults
and use of buprenorphine among this subgroup. Guidelines for treating CRediT authorship contribution statement
patients of culturally diverse and linguistic-minority backgrounds have
been outlined in the past (Center for Substance Abuse Treatment, 2006). Jenny Zhen-Duan: Conceptualization, Methodology, Formal anal­
However, these guidelines are loosely enforced nationally and rarely put ysis, Writing-original draft, Writing- review and editing. Marie Fukuda:
into practice (Guerrero et al., 2014; Torrey et al., 2011). For instance, Conceptualization, Formal analysis, Investigation, Writing – review &
despite the federal implementation of the National Culturally and editing, Project administration. Melissa DeJonckheere: Conceptuali­
Linguistically Appropriate Services (CLAS) Standards in 2000 to in­ zation, Methodology, Writing - original draft, Writing- review and
crease cultural and linguistic competence (Office of Minority Health, editing. Irene Falgas-Bagué: Conceptualization, Methodology, Writing-
2001), most states still do not meet all standards almost two decades review and editing. Steven Miyawaki: Validation, Investigation,
later (Aggarwal et al., 2017). While comprehensive adoption and Writing- review and editing. Parwana Khazi: Validation, Investigation,
implementation of CLAS standards may prove challenging (Aggarwal Writing – review & editing. Margarita Alegría: Conceptualization,
et al., 2017; Barksdale et al., 2014), the lack of payments to managed Methodology, Writing- review and editing, Supervision, Funding
care plans to attend to specific populations may influence the lack of acquisition.
SUD care for these subgroups. SUD care providers should implement
novel strategies to improve SUD care for linguistic minorities, older
Acknowledgement
adults, and those with dual diagnosis.
Stakeholders in our study perceived current quality metrics as not
Research reported in the current manuscript was supported by the
representing SUD treatment quality and also failing to capture the ex­
National Institute on Drug Abuse (NIDA) under award number
periences of individuals not interacting with the health care system. Our
R01DA044526. At the time of the study, Dr. Zhen-Duan was a Scholar
findings echo previous studies (Dunigan et al., 2014; Laudet, 2011;
with the HIV/AIDS, Substance Abuse, and Trauma Training Program
Morgenstern et al., 2008), suggesting that secure housing and employ­
(HA-STTP), at the University of California, Los Angeles; supported
ment are social needs that should be incorporated into these measures.
through an award from NIDA (R25DA035692). The content is solely the
Research should explore functional domains salient in promoting long-
responsibility of the authors and does not necessarily represent the
term recovery (Laudet, 2011). Currently, no consensus exists on which
official views of NIDA. The funders (NIDA) had no role in design and
social outcomes should be assessed in clinical settings (Cantor & Thorpe,
conduct of the study; collection, management, analysis, and interpre­
2018) due to a lack of policy standards around utilization of social
tation of the data; preparation, review, or approval of the manuscript; or
outcomes data (Freij et al., 2019). In response, NYS has an opportunity
decision to submit the manuscript for publication.
to create ways for SUD treatment centers to systematically track and
improve patients' social needs and quality of life. For example, based on
the participants' perspectives in this study, NYS could incorporate more Declaration of competing interest
patient-centered metrics of recovery (Neale et al., 2015; Neale et al.,
2016) and require improved quality of life for value-based care (i.e., None.
integration of primary care and SUD care history, including patient's
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