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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., Competing Interests: The authors report no financial relationships with commercial interests.

Importance: There is limited evaluation of the performance of Medicaid managed care (MMC) private plans in covering substance use disorder (SUD) treatment., Objective: To compare the performance of MMC plans across 19 indicators of access, quality, and outcomes of SUD treatment., Design Setting and Participants: This cross-sectional study used administrative claims and mandatory assignment to plans of up to 159 016 adult Medicaid recipients residing in 1 of the 5 counties (boroughs) of New York, New York, from January 2009 to December 2017 to identify differences in SUD treatment access, patterns, and outcomes among different types of MMC plans. Data from the latest years were received from the New York State Department of Health in October 2019, and analysis began soon thereafter. Approximately 17% did not make an active choice of plan, and a subset of these (approximately 4%) can be regarded as randomly assigned., Exposures: Plan assignment., Main Outcomes and Measures: Percentage of the enrollees achieving performance measures across 19 indicators of access, process, and outcomes of SUD treatment., Results: Medicaid claims data from 159 016 adults (mean [SD] age, 35.9 [12.7] years; 74 261 women [46.7%]; 8746 [5.5%] Asian, 73 783 [46.4%] Black, and 40 549 [25.5%] White individuals) who were auto assigned to an MMC plan were analyzed. Consistent with national patterns, all plans achieved less than 50% (range, 0%-62.1%) on most performance measures. Across all plans, there were low levels of treatment engagement for alcohol (range, 0%-0.4%) and tobacco treatment (range, 0.8%-7.2%), except for engagement for opioid disorder treatment (range, 41.5%-61.4%). For access measures, 4 of the 9 plans performed significantly higher than the mean on recognition of an SUD diagnosis, any service use for the first time, and tobacco use screening. Of the process measures, total monthly expenditures on SUD treatment was the only measure for which plans differed significantly from the mean. Outcome measures differed little across plans., Conclusions and Relevance: The results of this cross-sectional study suggest the need for progress in engaging patients in SUD treatment and improvement in the low performance of SUD care and limited variation in MMC plans in New York, New York. Improvement in the overall performance of SUD treatment in Medicaid potentially depends on general program improvements, not moving recipients among plans., Competing Interests: Conflict of Interest Disclosures: Drs Alegria, Falgas-Bague, and Rigotti and Ms Fukuda reported grants from National Institute on Drug Abuse (NIDA) during the conduct of the study. Ms O’Malley and Dr Stein reported grants from National Institutes of Health during the conduct of the study. Dr Layton reported personal fees from Greaylock McKinnon and Associates outside the submitted work. Dr Wallace reported grants from NIDA during the conduct of the study; additionally, his spouse is the Director of Medicaid Transformation and Financing at Aurrera Health Group. Dr Neighbors reported personal fees from Harvard University during the conduct of the study. Dr Wakeman reported personal fees from Celero Systems outside the submitted work. Dr Kane reported grants from the Health Resources and Services Administration outside the submitted work. No other disclosures were reported., (Copyright 2022 Alegría M et al. JAMA Health Forum.)

Background: Medicaid programs are vital to ensure low-income individuals have access to substance use disorder (SUD) treatment. However, shifts in Medicaid policies may alter coverage and SUD care for this population, who already face difficulties receiving high-quality SUD treatment. Using a policy implementation research approach, we sought to identify barriers and facilitators when transitioning from Medicaid fee-for-service to managed care 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), clinicians (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 inadequate 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., (Copyright © 2021 Elsevier Inc. All rights reserved.)