How Do Medicaid Agencies Improve Substance Use Treatment Benefits? Lessons from Three States' 1115 Waiver Experiences

Abstract

Context: In 2015, the Centers for Medicare and Medicaid Services urged state Medicaid programs to use 1115 waiver demonstrations to expand substance use treatment benefits. We analyzed four critical points in states’ pre-implementation decision-making processes to expand benefits. Methods: We conducted qualitative cross-case comparison of three states that were early adopters of the 1115 waiver request. We conducted 44 interviews with key informants from CMS, Medicaid and other state agencies, providers, and managed care organizations. Findings: Policymakers expanded substance use treatment in response to “fragmented” care systems and unsustainable funding streams. Medicaid staff had mixed preferences for implementing new benefits via 1115 waivers or state plan amendments. The 1115 waiver process enabled states to provide coverage for residential benefits, but state plan amendments made other services a permanent part of the benefit. Medicaid agencies relied on interorganizational networks to identify EBPs. Medicaid staff secured legislative support for reform by focusing on program integrity concerns and downstream effects of substance use, rather than the needs of Medicaid beneficiaries. Conclusions: Decision-making processes were influenced by Medicaid agency characteristics and interorganizational partnerships, not federal executive branch influence. Lessons from early adopter states provide a roadmap for other state Medicaid agencies considering similar reform.

Applying the EPIS framework to policy-level considerations: Tobacco cessation policy implementation among California Medicaid managed care plans

“…Research is needed to better understand how organizations respond to and implement health policies disseminated by federal and state-level entities. Prior work by Crable et al (2022a ) suggests that U.S. federal executive branch influence has a limited impact on state and provider implementation outcomes. Additionally, the decentralized nature of Medicaid benefit administration can promote outer/inner context and EBP misalignment, poor fidelity, and limited adoption of evidence-based benefit policies ( Crable et al, 2022b ).…”

Tailoring dissemination strategies to increase evidence-informed policymaking for opioid use disorder treatment: study protocol

“…The outer context includes influences at the federal (e.g., Centers for Medicare and Medicaid Services) and state level (e.g., governor, state legislature who can exert partisan influence) from leadership, state/federal policies (e.g., SUPPORT Act), funding and contracting arrangements that impact the service environment, perceptions/stigma toward Medicaid/CHIP members, and advocacy groups that lobby for or against MOUD. Prior research on opioid use disorder treatment policy highlights the important influence that state legislators and governors have over access to care [6,[67][68][69], and we expect those outer context political entities to similarly influence Medicaid policymaker decisions about MOUD policies.…”

Where is “policy” in dissemination and implementation science? Recommendations to advance theories, models, and frameworks: EPIS as a case example

“…For example, was the policy developed by agency staff, an expert workgroup, via a collaborative process with the public or advocacy groups? Understanding the origin story creates transparency in the policymaking process [ 11 ] to reveal the nature of “evidence” (e.g., research vs. personal beliefs) used to inform decisions and the types of interests represented during policy development. Social network analysis can aid in identifying actors involved in the policy’s creation.…”

“…Relational ties, like partnerships between government agencies and provider organizations, can also represent bridging factors . Stakeholders (e.g., lobbyists, consultants, advocates) who support the passage of a policy in the outer context and its implementation in the inner context serve in bridging factor roles [ 11 , 50 ]. Researchers should investigate personal (e.g., financial) and professional (e.g., influence) gains individuals receive from serving as a bridging factor .…”

“…Health policies can serve as implementation strategies that facilitate or mandate access to evidence-based health services [ 7 – 9 ]. Health policies can also represent the evidence-based law, rule, or “thing” [ 10 ] at the center of implementation efforts [ 5 , 11 – 14 ], act as determinants that enable or constrain D&I strategies from achieving desired outcomes [ 5 , 15 – 17 ], and potentially serve in other causal pathway roles (e.g., mechanisms).…”