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This observational study examines changes in access to methadone maintenance treatment following Oregon's decision to remove substance abuse treatment from the Medicaid benefit for an expansion population. Access was compared before and after the benefit change for two cohorts of adults addicted to opiates presenting for publicly funded treatment. Propensity score analysis helped model some selective disenrollment from Medicaid that occurred after the benefit change. Logistic regression was used to compare access to methadone by cohort controlling for client characteristics. Opiate users presenting for publicly funded treatment after the change were less than half as likely (OR = 0.40) to be placed in an opiate treatment program compared to the prior year. Further analysis revealed that those with no recent treatment history were less likely to present for treatment after the benefit change. These results have implications for states considering Medicaid cuts, especially if the anticipated increases in illegal activity, emergency room utilization, unemployment, and mortality can be demonstrated.

Objective: Mental health services are important to treatment retention and positive outcomes for many clients of substance abuse treatment programs. For these clients the implementation of managed care should provide for continued or increased access to mental health treatment, rather than decreased access because of short-term, cost-reduction objectives. This study assessed whether converting Medicaid from a fee-for-service program to a capitated, prepaid managed care program affected access to mental health services among clients who were treated for substance abuse., Methods: Medicaid enrollees who were being treated for substance abuse in Oregon were interviewed before beginning treatment and after six months of service. One cohort (N=53) was interviewed one to six months before the implementation of managed care, a second (N=66) was interviewed two years after the implementation, and a third (N=49) was interviewed three to four years after the implementation. Logistic regression analyses were used to identify whether the implementation of managed care, the psychiatric need of the client, and other client characteristics affected the receipt of mental health services during the first six months of substance abuse treatment., Results: Clients in all three cohorts had similar characteristics. The implementation of managed care did not affect whether clients received mental health services. A baseline interview score that was derived from items in the Addiction Severity Index psychiatric section was the only client characteristic that predicted receipt of mental health services., Conclusions: Although this study was a naturalistic experiment with many methodologic flaws, it provided a unique opportunity to observe whether the introduction of managed care changed access to mental health services among Medicaid enrollees who were being treated for substance abuse.

Context: The shift to Medicaid managed care has raised numerous concerns about access to publicly funded substance abuse treatment. The implementation of a capitated chemical dependency benefit within the Oregon Health Plan in 1995 provided an opportunity to study the impact of funding mechanisms on access., Objectives: To determine to what extent access to publicly funded substance abuse treatment changed following the shift to managed care in Oregon and to examine factors associated with that change., Design: Analysis of statewide treatment and Medicaid eligibility data., Setting and Patients: All Medicaid-eligible persons aged 12 to 64 years who were enrolled in the Oregon Health Plan during 1994 (88,320), 1996 (170,387), 1997 (160,929), or 1998 (149,877)., Main Outcome Measures: Access rates (the number of unique individuals admitted to treatment during a calendar year divided by the average number of enrolled members) computed before (1994) and after (1997) implementation of the capitated benefit. Analyses were replicated with data for 1996 and 1998., Results: The percentage of Medicaid-eligible persons admitted to substance abuse treatment programs during a calendar year increased from 5.5% of the average number of enrolled members per month in 1994 to 7.7% in 1997, following the shift to managed care. For 1996 and 1998, the rates were 6.9% and 7.7%, respectively. Access rates varied considerably among the 7 largest prepaid health plans after adjusting for case mix. Operating characteristics of these prepaid health plans, such as the method of reimbursing treatment providers, were significant predictors of access after controlling for member characteristics., Conclusion: According to our analyses, Medicaid-eligible persons in Oregon observed an increase in access to substance abuse treatment after a shift to managed care. JAMA. 2000;284:2093-2099.