Unpacking Disparities in Opioid Use Disorder Treatment Quality

PROJECT SUMMARY
Over 2 million people are now estimated to have an opioid use disorder (OUD). The U.S. health care system is
struggling to meet this challenge, as the need for OUD treatment far exceeds the supply of qualified clinicians
who can prescribe and monitor medications for opioid use disorder (MOUD). MOUD are effective at reducing
overdose deaths and improving outcomes, but are vastly underused, with only 25-40% of adults with OUD
receiving MOUD. Rates of OUD are particularly high among Medicaid enrollees, and Medicaid is the largest
payor of OUD treatment services. Studies have demonstrated racial, ethnic, geographic, and age differences in
overdose death rates, patterns of opioid drug use and OUD, and patterns of treatment. Yet, few studies have
undertaken more nuanced approaches to examining the quality of OUD care that take into account differences
that may compound across dimensions such as race, gender, and age groups, referred to as intersectionality.
Observed disparities may reflect regional limitations in available treatment providers as well as differences in
upstream pathways to diagnosis and treatment (e.g., care after an overdose, access to primary care).
Using real-time Medicaid claims data from North Carolina, supplemented by claims from Medicare and private
insurance (with these sources together accounting for over three-quarters of all North Carolina residents) will
allow us to characterize the quality of OUD care delivered by each provider across payers. We will examine
differences in OUD care quality by intersectional status and examine key drivers of those differences. Our first
aim is to assess differences in the quality of OUD care by intersectional status. We will also examine whether
the presence of other chronic behavioral health and medical conditions moderate these disparities in OUD care
quality by intersectional status. Our second aim is to assess the extent to which differences in the receipt of
high-quality OUD care by intersectional status are due to differences in the availability of providers who provide
high-quality OUD treatment, by geographic areas. Finally, our third aim is to compare differences by
intersectional status in the receipt of high-quality OUD care before, during, and after North Carolina transitions
its Medicaid program from fee-for-service to capitation in July 2021. We will use national Medicaid data to
compare patterns of OUD care quality in North Carolina to the country as a whole. We will also explore the use
of electronic health record data to provide an alternative assessment of OUD quality of care by examining
clinician notes, orders, and lab tests. 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. Our results will guide policy and practice aimed at improving OUD care engagement and
quality for all individuals.