Federal Government and States Should Assess Addiction Treatment in Correctional Facilities
Medicaid coverage of opioid use disorder care requires outcome measurement
Congress, the Biden administration, and some state governments have recently taken steps to cover opioid use disorder (OUD) treatment in jails and prisons through Medicaid, the public health insurance program for low-income Americans. This represents a major policy and financing change following long-standing program limitations on use of Medicaid for people who are incarcerated. Pressure from public health advocates has been mounting for such a change because of increased concern over the opioid overdose crisis and its impact in communities, but the change must be accompanied by standards and performance measures for treating this population. In response to this increased interest, Medicaid’s policy on covering health care in jails and prisons is evolving.
Data since 2000 shows that drug and alcohol intoxication deaths in jails and prisons have increased dramatically. Additionally, individuals recently released from jail or prison are at extremely high risk of dying from a drug overdose. Providing medications for opioid use disorder (MOUD) to people while they are incarcerated has been found to increase their engagement in treatment after re-entry to the community, yet few facilities do so, at least in part because of a reported lack of adequate funding to pay for this care.
A report by Viaduct Consulting LLC released in early October, the first in a series supported by Bloomberg Philanthropies on OUD care in jails and state prisons, recommended services and standards for Medicaid coverage of OUD treatment. The second report in this series details performance measures for correctional facilities providing such care.
This new report suggests that as the Centers for Medicare and Medicaid Services (CMS) and states are considering Medicaid coverage in correctional facilities, they should develop clear treatment goals, measurable objectives, and metrics. Doing so would allow the agencies to monitor and evaluate how well correctional facilities, health and behavioral health providers, and managed care partners meet their objectives and ultimately improve care and health outcomes for incarcerated and newly released Medicaid beneficiaries with OUD. The recommended measures, developed in conjunction with the services and standards recommended in the first report, likewise include screening, assessment, MOUD, counseling, and services to support re-entry.
Recommended measures
The report’s authors suggest that to best capture program performance and results, CMS should require state Medicaid authorities to track and report data on some measures and make others optional. Many of these recommendations (excerpted below) are based on existing OUD measures used in the community; others are specific to state and local efforts to measure the impact of providing OUD services in correctional facilities.
Medicaid OUD Measures at Admission to a State or Local Correctional Facility
| Measure | Required or Encouraged |
|---|---|
| Percentage of Medicaid beneficiaries screened for OUD using a standardized screening tool during the measurement period | Required |
| Percentage of Medicaid beneficiaries who had a documented OUD diagnosis (e.g., on insurance claim or electronic health record) during the measurement period | Required |
| Percentage of Medicaid beneficiaries with OUD who initiate MOUD, by type of MOUD (methadone, buprenorphine, or naltrexone), while in a jail or prison | Required |
| Percentage of Medicaid beneficiaries continuing community-initiated MOUD at admission | Required |
Medicaid OUD Measures During Incarceration
| Measure | Required or Encouraged |
|---|---|
| Percentage of individuals who filled or were prescribed and dispensed an MOUD who received the MOUD for at least six months overall, and by type of MOUD (methadone, buprenorphine, or naltrexone) | Required |
| Percentage of Medicaid beneficiaries who changed MOUD (by type) while in jail or prison | Encouraged |
| Number and rate of overdose deaths for Medicaid beneficiaries during incarceration | Required |
Medicaid OUD Measures During Re-entry
| Measure | Required or Encouraged |
|---|---|
| Percentage of Medicaid beneficiaries with an OUD who were dispensed an MOUD (by type of medication: methadone, buprenorphine, naltrexone) as well as naloxone on the day they re-entered the community | Required |
| Percentage of adult individuals leaving incarceration with Medicaid coverage | Required |
Medicaid OUD Measures Post-Reentry
| Measure mended measure | Required or Encouraged |
|---|---|
| Follow-up after release from a jail or prison: percent of Medicaid beneficiaries released from jails or prisons that result in a follow-up visit or service for OUD within seven- and 30-days post-reentry | Required |
| Number and rate of overdose deaths for Medicaid beneficiaries one month and six months post-re-entry | Required |
| Percentage of Medicaid beneficiaries who received an MOUD for at least 60 and 90 days and by type of MOUD (methadone, buprenorphine, or naltrexone) | Required |
| Percentage of Medicaid beneficiaries who return to jails and prisons post-reentry | Encouraged |
| Percentage of Medicaid beneficiaries reporting positive recovery-related outcomes post-reentry | Encouraged |
Other
| Measure | Required or Encouraged |
|---|---|
| Number and percent of jails and prisons that participate as Medicaid providers in the state’s Medicaid program during the 1115 demonstration period | Required |
Data reporting challenges
Data is necessary for Medicaid agencies to assess service provision and quality, and for jails and prisons to customize OUD program improvements. Data reporting is required in the community for the Medicaid program, and some form of reporting will be required for Medicaid coverage of correctional health care.
However, correctional facilities frequently lack the infrastructure to provide OUD services and report data that tracks performance. Some jails and prisons lack electronic health records and the technological capability to submit claims, and correctional staff members seldom have experience in claims submission and coding.
In order to begin collecting this measurement data, correctional agencies at the state and local levels will need resources and technical assistance. CMS allows state Medicaid authorities to underwrite initial efforts to create or enhance infrastructure in jails and prisons, but the agencies will also need to develop simple yet sufficient policies and procedures to monitor and measure performance. The report authors recommend that CMS and state Medicaid authorities use this report to help make decisions with their state and local correctional partners about how best to gather information and report on these measures. This could be done with input from federal and state policymakers, health care providers and community-based organizations, Medicaid managed care organizations, people who have direct experience with incarceration and OUD, and advocates.
The third and final report in this series, to be published early next year, will focus on suggested reimbursement and payment models.
Alexandra Duncan works on The Pew Charitable Trusts’ substance use prevention and treatment initiative. Maria Schiff is a consultant for Pew.
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