Unpacking Disparities in Opioid Use Disorder Treatment Quality

Unpacking Disparities in Opioid Use Disorder Treatment Quality Unpacking Disparities in Opioid Use Disorder Treatment Quality The U.S. is still in the midst of a widespread opioid use epidemic. From 1999 to 2019 almost 500,000 people died from an opioid overdose (1), and over 2 million are now estimated to have an opioid use disorder (OUD) (2). OUD prevalence is disproportionately high among Medicaid enrollees (3, 4). The need for treatment far exceeds the supply of clinicians that prescribe and monitor medications for OUD (MOUD) (5, 6). MOUD are effective at reducing overdose deaths and improving outcomes, but are vastly underused, with only 25-40% of adults with OUD receiving MOUD (7-9). Emerging data suggest racial and ethnic disparities in the quality of care and outcomes for OUD. Studies have demonstrated racial, ethnic, geographic, age, and socioeconomic status (SES) differences in overdose death rates (10-14), patterns of opioid drug use and OUD (15-18), and patterns of treatment (19-22). Better estimates using more sophisticated approaches to examining health equity are sorely needed. Few studies do more than scratch the surface of equity in OUD care; ideally such research would examine a combination of types of treatment and duration of care that takes into account differences that may compound across dimensions such as race, gender, and age group, referred to as intersectionality. Disparities may be exacerbated by differences in the regional availability and quality of care. Greater distance to MOUD prescribers is known to be associated with lower odds of receipt and continuity of MOUD (23); counties with higher-than-average rates of OUD typically have low treatment capacity; and there are racial/ethnic disparities in the availability of MOUD providers in neighborhoods segregated by race/ethnicity (24). Important changes in the clinical and practice environment have the potential to substantially interrupt patterns of care, disproportionately affecting Black and Latinx communities (25). The long-term implications of the COVID-19 pandemic are unknown, including the impact on the quality of care for OUD and further exacerbations of previous disparities in care (26). North Carolinas (NC) recent transformation of its Medicaid program offers an opportunity to examine an innovative set of high-powered incentives to advance equity. Using real-time NC Medicaid claims data, supplemented by claims from Medicare and private insurance (together accounting for over 75% of state residents) that will allow us to characterize provider level OUD care quality across payers, we will examine differences in OUD care quality by Medicaid beneficiaries intersectional status and examine key drivers of differences in quality. We will use national Medicaid data to compare patterns of OUD care quality in NC to the US as a whole and explore the use of electronic health record (EHR) data to provide an alternative assessment of OUD quality. Our aims are: Aim 1: Assess differences in the quality of OUD care by intersectional status, prior to and during the COVID-19 pandemic. H1.1: Older adults, Blacks, and men receive lower quality OUD care and the differences are most striking at the intersection of these identities. H1.2: Comorbid behavioral health and other chronic conditions exacerbate the relationship between intersectional status and quality of care. H1.3: Regional factors such as rurality and other social determinants of health modify differences in the quality of OUD care. H1.4: The receipt of high-quality OUD care declined during COVID and pre-COVID differences in care by intersectional status have been exacerbated during the pandemic. Aim 2: Assess the extent to which differences in the receipt of high-quality OUD care are due to differences in the availability of providers who provide high-quality OUD treatment by geographic area. H2.1: There are quality of care differences between providers who treat individuals from historically marginalized backgrounds with OUD. H2.2: Because of historical and ongoing residential segregation by race/ethnicity due to structural racism, there are differences in the closest distance to a high quality versus low quality provider for Medicaid beneficiaries of diverse racial/ethnic backgrounds with OUD. Aim 3: Compare differences by intersectional status in the receipt of high-quality OUD care prior to and after NC Medicaids transition to managed care. H3.1 Because of the emphasis on improving both quality and health equity, differences in the quality of care received by intersectional status will decrease. Understanding the differences in OUD care quality by intersectional status and the factors underlying and driving those differences is critical to attaining an equitable, high-quality health care system. By identifying intersectional groups receiving lower quality of care and drilling down on the contextual factors surrounding these differences, including the local availability of high-quality providers, our results will guide policy makers in designing a smarter set of incentives aimed at improving OUD care engagement and quality for all individuals.