Uncovering Barriers to Engagement in Substance Use Disorder Care for Medicaid Enrollees
Abstract
Objective:
The authors aimed to uncover factors that affect engagement in substance use disorder treatment among Medicaid beneficiaries in New York State.
Methods:
The authors conducted 40 semistructured interviews with clients, plan administrators, health care providers, and policy leaders directly involved with substance use care in New York State. Data were analyzed with thematic analysis.
Results:
Main themes resulting from analysis of the 40 interviews showed that most stakeholders agreed that a need exists to better integrate psychosocial services into behavioral health care systems; that systemic stigma, stigma from providers, and lack of cultural responsiveness in the substance use care system hinder engagement in and provision of high-quality care; and that rural health care networks with coordinated models benefit clients’ engagement in care.
Conclusions:
Stakeholders involved in care for substance use disorder perceived a lack of integration of resources to meet clients’ social needs, the presence of stigma, and low levels of cultural and linguistic capacity as key factors contributing to low engagement in and low quality of care for substance use disorder. Future interventions should address social needs within the therapeutic regimen and modify curricula in clinical training to reduce stigma and increase cultural competence.
HIGHLIGHTS
•
Care for substance use disorder provided under Medicaid in New York State fails to address clients’ social needs, thus hindering treatment engagement and adequate care.
•
Peer support services are perceived as a key component for treatment engagement and should be incorporated as a billable service under Medicaid.
•
Stigma among providers toward people with substance use disorders and gaps in language capacity can negatively affect treatment engagement and provision of high-quality services.
Engagement in substance use disorder treatment has been historically limited, reducing the beneficial effects of treatment (1, 2). Treatment engagement, that is, the initiation and maintenance of client participation in treatment (3), is strongly associated with high-quality care for substance use disorder and reflects treatment that meets clients’ needs (4). Engagement is essential in preventing relapse, incarceration (5), and death from substance use (6). Factors contributing to engagement in substance use disorder treatment can be described at the individual, provider, policy, and organizational levels (7–9). Most previous research has studied barriers and contributors to substance use disorder treatment engagement at each level but has investigated them separately (9–11). For example, symptom severity, internal motivation (4, 12), availability of tangible resources linked to treatment (e.g., housing provision in exchange for treatment) (13, 14), and strong interpersonal relationships with providers (12–15) contribute to treatment engagement at the individual level. However, few studies have integrated the factors influencing treatment engagement at these different levels.
In this study, we aimed to uncover factors that affect treatment engagement and identify pathways to high-quality care for substance use disorder for Medicaid beneficiaries in New York State. We integrated perspectives from diverse stakeholders within Medicaid health care insurance plans, the largest insurer for vulnerable low-income communities in the United States.
Methods
Study Design
This study was part of a larger project evaluating the quality of Medicaid managed care for substance use disorder in New York State (16). We conducted interviews with stakeholders (i.e., clients, Medicaid managed care plan administrators, policy leaders, and clinicians). Medicaid managed care plans provide for the delivery of Medicaid health care benefits and additional services through contracted agreements between state Medicaid agencies and managed care organizations (17).
Participants were shown publicly available performance indicator data on substance use disorder treatment access, quality, and outcomes and were asked to share their perspectives on the factors driving the performance of different insurance plans (see the online supplement to this article). An insurance plan, as defined by the Centers for Medicare and Medicaid Services, is “the pairing of health insurance coverage benefits under a product and a particular cost-sharing structure, provider network, and service area” (18). Participants also shared their perceptions of general barriers to accessing high-quality care for substance use disorder. The study was approved by the Mass General Brigham Institutional Review Board.
Participants and Recruitment
Study participants were directly involved in key aspects of care for substance use disorder. Policy leaders included state employees, advocacy leaders, and scholars focused on policies. Clinicians included primary care and internal medicine physicians, a psychiatrist, and therapists treating people with substance use disorders. Clients were individuals receiving outpatient treatment for substance use disorders, including pharmacological treatments and psychotherapy. Finally, plan administrators were employed within different Medicaid managed care organizations in the field of behavioral health care. (Detailed information on participants’ backgrounds and sociodemographic characteristics and clinicians’ workplace characteristics is in the online supplement .) Policy leaders were contacted by our study partners and through snowball techniques, such that a participating policy leader referred other potential participants. We obtained a list of Medicaid managed care plans operating in New York and either directly contacted people for recruitment or requested support from our partners to be connected with key personnel within these plans. Of the plan administrators to whom we reached out, only one did not respond, and we interviewed participants from 10 plans. Additionally, we contacted providers from an array of clinical settings (e.g., inpatient treatment, harm-reduction clinics, and offices mostly targeting mandated treatment clients) to ensure diversity of recruited participants. Client participants were referred by clinicians from these varied clinical settings.
Procedure
We conducted in-depth semistructured interviews by using a list of predetermined questions (19). Interviews were conducted between February and November 2020. Interview guides were refined during data collection and were tailored to each stakeholder group. Interviews were conducted by trained research staff via phone, except for client interviews, which were conducted in person. Consent was obtained for all interviews. Participants were compensated with a $100 gift card.
Analysis
Verbatim interview transcripts were deidentified and uploaded to an online platform for qualitative data analysis (20). We used qualitative thematic analysis (21). During data collection, researchers reviewed transcripts to become acquainted with the data. A codebook was developed a priori on the basis of the interview guide and study objectives and was then iteratively refined as the research team reviewed and coded the data. Once the codebook was finalized, two trained team members independently coded transcripts and reviewed and resolved coding discrepancies with a third member. Coders proceeded with independent coding and resolution, periodically checking with the research team to resolve discrepancies (22). Broad emergent themes were identified and generated by patterns of responses across and among stakeholder groups (21). All members of the research team further reviewed and clarified the themes to develop the findings presented here.
Results
Of the 88 stakeholders invited, 40 agreed to participate, including clients (N=10), plan administrators (N=10), clinicians (N=10), and policy leaders (N=10) (see Table S1 in the online supplement ).
Theme 1: Failure to Integrate Community Outreach and Psychosocial Services
Across stakeholder groups, community outreach and integration of psychosocial services were touted as essential components of engagement in substance use disorder treatment and high-quality care. However, stakeholders perceived that certain barriers prevented these components from being more widely integrated into the behavioral health care system. The identified challenges were that services targeting psychosocial needs have not been well incorporated into substance use disorder treatments, that financing procedures have hindered the expansion of psychosocial interventions, and that the role of peers in engagement has been undervalued.
Insufficient incorporation of services targeting psychosocial needs.
All stakeholder groups expressed their perception that people with substance use disorders are often affected by psychosocial issues and that a more holistic approach to care is needed to address food instability, financial stressors, and a lack of housing. One plan administrator, who also held clinical roles, pointed out the importance of education about these barriers.
I used to teach my students, “You’re telling me that she’s a single mother with four young children who’s about to be evicted, and her food stamps do not cover her children’s food needs for any month, so she’s always running out of food. So, you want us to refer her to the psychiatrist to put her on medication and have her come for therapy? Perhaps we ought to look at the fact that she has housing instability and food insecurity first before we make her a patient.” (participant 42)
Similarly, one clinician, working in a community-based clinic, noted that addressing psychosocial barriers such as housing challenges, immigration statuses, and familial disputes could aid in the reduction of substance use. Finally, clients emphasized the importance of addressing social needs as part of treatment for substance use disorder.
What do you think is the most important part of substance abuse services; like, what do you think is needed for people to be able to maintain sobriety if they wanted to? Shelter, you know what I mean? . . . I needed food, clothes, and shelter. (participant 55)
Additionally, clinicians and policy leaders believed that an emphasis on medication and a lack of focus on addressing underlying needs foster the use of interventions that are missing a characteristic of treatment they perceived as essential for success: adaptability to individual circumstances.
Medicaid financing procedures and insufficient expansion of psychosocial interventions.
Clinicians, policy leaders, and plan administrators argued that implementation of interventions that address psychosocial needs face significant financial barriers. They believed that with more investment, a larger pool of providers could incorporate psychosocial treatment approaches, keeping more clients engaged. One policy maker expressed that investment in communities by the Office of Addiction Services and Supports through work with community health centers and community-based organizations could facilitate substance use disorder treatment.
Clinicians and plan administrators alike expressed concerns about financial barriers, emphasized the need for investment to integrate these treatments, and outlined differences in provision of social services—depending on the insurance plan or reimbursement model that is used (see the online supplement for supporting quotations)—such as wraparound services or case management assistance to address needs related to social determinants of health (e.g., employment, housing, and food).
The undervalued role of peers in substance use disorder treatment engagement and outcomes.
One of the most valuable, yet underutilized, resources identified by participants was peer-based recovery support, which aims to engage clients through individual support and health care navigation. Peer mentors are those with lived experience who function as mentors or recovery advocates within a coordinated recovery plan (23, 24). Examples of peer services include legal services, child care, employment coaching, and service guidance (24). One client outlined their perception of the importance of peer support in care navigation.
It’s very confusing—working [by] yourself, trying to get these things done, and going to these places where they turn their back on you—and you don’t know. Because a peer knows what the rules and regulations are, what the hospitals can do or cannot do to a patient. (participant 49)
Theme 2: Provider Stigma Undermining Treatment Outcomes
Stakeholders identified provider stigma as a barrier that negatively affects treatment engagement. Several clinicians advocated for expansion of harm-reduction approaches to lessen stigma and provide more humane care. At the individual level, harm-reduction approaches may include increased training of providers to encourage client-centered care.
One clinician described their experiences with provider stigma as follows:
I think people who use drugs are stigmatized, they’re mistreated, they’re called junkies, they’re ignored, their pain is ignored, [and] they are seen as liars [and] malingerers; they might even be restrained, they might be chastised for having overdosed, they might be scolded. All of these things do harm when we think about ongoing engagement in the health care system. (participant 45)
These experiences were echoed by clients.
When you go to the emergency room, and they say, “Oh, are you a drug user? Are you on any medication, like methadone?” and all that. “Yeah, I’m on methadone.” “Okay, you wait over there. Next!” . . . Because you say you use drugs, and they judge you. (participant 55)
Although stigmatization by providers was described extensively, solutions were rarely mentioned. However, some stakeholders suggested educating new doctors early in their careers about stigma related to substance use. Overall, stigma surrounding substance use was described by all stakeholder groups, and addressing stigma was seen as a priority to achieving higher-quality care for individuals with substance use disorder.
Theme 3: Effects of Geography and Lack of Cultural Responsiveness on Quality of Care
Other frequently mentioned components of access and engagement included factors related to culturally diverse client populations and to clients living in rural areas. Identified subthemes included the perception that cultural and linguistic barriers affect therapeutic relationships and that the level of coordination typical in rural settings is beneficial for care engagement.
Stakeholders emphasized their desire to improve treatment access for people from racial-ethnic and linguistic minority groups. Clients, policy leaders, and clinicians expressed their perceptions of the importance of linguistic and cultural competence for ensuring treatment engagement and maintaining rapport with providers (see the online supplement ). Concerns from both clients and clinicians included the lack of capacity among providers to speak languages other than English, which impinges on the provision of high-quality care, especially in urban settings where cultural and linguistic diversity is prevalent.
According to some participants, providers can seek a model for collaboration in rural settings, where working relationships among providers form a network that fosters coordinated services. Participants expressed their beliefs that, although rural settings have fewer options for treatment, connections among providers in these areas facilitate more successful provision of care, suggesting the importance of efficient communication among providers, especially when treatment access is lacking.
Discussion
This study uncovered perspectives on significant challenges that hinder engagement in and provision of high-quality care for substance use disorder. Most of the described barriers were echoed by all stakeholder groups. One of the most significant challenges described was the integration of social interventions into the health care system to address social determinants of health and improve treatment outcomes (27, 28).
In New York State, several Medicaid managed care plans have recently increased efforts to incorporate case management services within the system of care for substance use disorder (29, 30). However, stakeholders described how these interventions do not meet clients’ particular needs and are delivered without consideration of important social determinants of health, such as housing concerns or language barriers. Nonetheless, health care organizations nationwide are experimenting with ways to address clients’ needs, including increasing housing and food security to improve public health while controlling costs of care (31). Potential strategies to increase provision of social resources within care for substance use disorders include implementing psychosocial interventions by integrating trained peer support workers or lay community health workers within existing health care facilities. The community health worker model has been shown to be an effective option for increasing the workforce and reducing costs while maintaining high-quality provision of evidence-based practices (32, 33).
Another possibility would be to include referral to social services in all intake visits to increase systematic provision of social resources. The growth of accountable care organizations and other value-based payment models resulted from the Affordable Care Act, which extended Medicaid coverage for people receiving substance use disorder treatment. This coverage has created new opportunities to use health care funding to improve population health with more flexibility (34). Current Medicaid regulations allow states to pay health care organizations to connect clients with basic social supports (30, 35, 36). Other states with expanded Medicaid programs, such as California (37), Colorado (38), and Oregon (39), have implemented new strategies to cover case management services, which include assessing clients’ social needs and referrals to nonmedical services (40, 41). Expanding peer support and social prescribing, which encourages connections between health care entities and social resources (42), is another potential solution to this integration gap that could be accomplished by incorporating a formal referral process to social and community resources (i.e., certified community-based organizations offering social support) within the Medicaid reimbursement system (43). However, these services are still considered emerging interventions and have not been systematically implemented within most national health care systems (44).
Our findings also highlight the role that stigma plays in reducing the quality of care for substance use disorder. Clients discussed negative personal experiences that have prevented their engagement with substance use disorder services (2). Similarly, providers emphasized the importance of increasing substance use disorder education in general medical training, focusing on harm-reduction approaches and emphasizing a chronic-condition framework for treatment. Such adoption is slowly being implemented within the health care system (45, 46). Few academic and medical institutions in the United States provide training on care for substance use disorder for future health care providers that incorporates pedagogical approaches for destigmatizing these disorders in curricula (47). The systematic implementation of such training is still rare. Moreover, continual training is needed for providers offering substance use disorder treatment, and policies encouraging completion of this instruction should be considered to ensure general implementation and to increase its impact on clients’ service experiences. Systemic stigma and stigmatizing attitudes of providers toward individuals with substance use disorder have been constant across most health care settings (48). Increased awareness, along with new, effective antistigma interventions (49–51) and newly released federal funding, might lead to assessing the prevalence of and reducing stigma at all levels (52).
Finally, increasing engagement in and improving quality of care for substance use disorder require adapting services to people’s specific needs, including by increasing language capacity and cultural competence and by coordinating services as is done in rural areas. In New York State, providers’ lack of the necessary linguistic capacity (16) and cultural competence to meet clients’ needs underscores the need for greater effort to increase provision of substance use disorder care to those with lower English proficiency. Implementing strategies to improve cultural competence at the provider and organizational levels is key to increasing engagement of diverse populations in care (53). In contrast with research indicating barriers to access and engagement in rural areas (54), our results highlight that the rural health care system is a potential facilitator of engagement and overall high quality of care for substance use disorder, given the high levels of coordination and collaboration among stakeholders in these settings (55). More research is needed to uncover the specific mechanisms underlying this observation and identify ways to simplify health care systems to transfer the benefits of rural contexts to urbanized regions (56).
A major strength of this study was that it highlighted the pragmatic challenges to delivering and receiving high-quality care for substance use disorder, with an emphasis on treatment engagement in New York State. To our knowledge, ours is one of a few studies that have considered feedback across diverse stakeholders involved in substance use disorder care. However, we acknowledge several limitations. First, the analysis was restricted to substance use disorder treatment of Medicaid-enrolled patients in one state, and care experiences may differ across states and settings. Second, our recruitment procedures may have left out the perspectives of clients who experienced difficulties accessing and remaining in care. Despite these limitations, this study adds to the existing literature by pointing out gaps in care that occur at different levels of the health care system.
Conclusions
Medicaid-provided treatment for substance use disorder faces significant challenges to achieving high rates of treatment engagement and, therefore, to the provision of high-quality care. All stakeholder groups agreed that limited integration of resources to meet social needs, systemic stigma and stigma from providers, and low levels of providers’ cultural and linguistic capacity pose major barriers that hinder engagement in and the quality of substance use disorder services. Interventions could redesign substance use disorder care to prioritize social needs as part of the care continuum and to encourage nonstigmatized treatment approaches, such as harm reduction, in order to reduce stigma from providers and improve overall care.
Acknowledgments
The authors acknowledge Liao Zhang, M.D., Carolina Diaz San Francisco, B.A., and Paola Del Cueto, M.D., for interviewing participants and leading data collection; Melissa Dejonckheere, Ph.D., for her input on and revision of the manuscript; and the participants of this study for taking the time to share their perspectives, allowing for valuable insight into their experiences.
Supplementary Material
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Information & Authors
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Published In
History
Received: 6 April 2022
Revision received: 10 March 2023
Accepted: 13 March 2023
Published online: 18 April 2023
Published in print: November 01, 2023
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Competing Interests
The authors report no financial relationships with commercial interests.
Funding Information
This study was supported by NIH (award R01 DA-044526 to Drs. Alegría, Zhen-Duan, and Falgas-Bague, Ms. Fukuda, and Ms. Markle).The content of this article is solely the responsibility of the authors and does not necessarily represent the official views of the NIH. The funders had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; or decision to submit the manuscript for publication.
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