Internal and Environmental Predictors of Physician Practice Use of Screening and Medications for Opioid Use Disorders.

Medications for opioid use disorder (MOUD) remain highly inaccessible despite demonstrated effectiveness. We examine the extent of screening for opioid use and availability of MOUD in a national cross-section of multi-physician primary care and multispecialty practices. Drawing on an existing framework to characterize the internal and environmental context, we assess socio-technical, organizational-managerial, market-based, and state-regulation factors associated with the use of opioid screening and offering of MOUD in a practice. A total of 26.2% of practices offered MOUD, while 69.4% of practices screened for opioid use. Having advanced health information technology functionality was positively associated with both screening for opioid use and offering MOUD in a practice, while access to on-site behavioral clinicians was positively associated with offering MOUD in adjusted models. These results suggest that improving access to information and expertise may enable physician practices to respond more effectively to the nation's ongoing opioid epidemic.

Do benefits restrictions limit Medicaid acceptance in addiction treatment? Results from a national study.

OBJECTIVE: To assess the relationship of restrictions on Medicaid benefits for addiction treatment to Medicaid acceptance among addiction treatment programs. DATA SOURCES: We collected primary data from the 2013-2014 wave of the National Drug Abuse Treatment System Survey. STUDY DESIGN: We created two measures of benefits restrictiveness. In the first, we calculated the number of addiction treatment services covered by each state Medicaid program. In the second, we calculated the total number of utilization controls imposed on each service. Using a mixed-effects logistic regression model, we estimated the relationship between state Medicaid benefit restrictiveness for addiction treatment and adjusted odds of Medicaid acceptance among addiction treatment programs. DATA COLLECTION: Study data come from a nationally-representative sample of 695 addiction treatment programs (85.5% response rate), representatives from Medicaid programs in forty-seven states and the District of Columbia (response rate 92%), and data collected by the American Society for Addiction Medicine. PRINCIPAL FINDINGS: Addiction treatment programs in states with more restrictive Medicaid benefits for addiction treatment had lower odds of accepting Medicaid enrollees (AOR = 0.65; CI = 0.43, 0.97). The predicted probability of Medicaid acceptance was 35.4% in highly restrictive states, 48.3% in moderately restrictive states, and 61.2% in the least restrictive states. CONCLUSIONS: Addiction treatment programs are more likely to accept Medicaid in states with less restrictive benefits for addiction treatment. Program ownership and technological infrastructure also play an important role in increasing Medicaid acceptance.

Inernational research in health care management: its need in the 21st century, methodological challenges, ethical issues, pitfalls, and practicalities.

PURPOSE: This commentary argues in favor of international research in the 21st century. Advances in technology, science, communication, transport, and infrastructure have transformed the world into a global village. Industries have increasingly adopted globalization strategies. Likewise, the health sector is more internationalized whereby comparisons between diverse health systems, international best practices, international benchmarking, cross-border health care, and cross-cultural issues have become important subjects in the health care literature. The focus has now turned to international, collaborative, cross-national, and cross-cultural research, which is by far more demanding than domestic studies. In this commentary, we explore the methodological challenges, ethical issues, pitfalls, and practicalities within international research and offer possible solutions to address them. DESIGN/METHODOLOGY/APPROACH: The commentary synthesizes contributions from four scholars in the field of health care management, who came together during the annual meeting of the Academy of Management to discuss with members of the Health Care Management Division the challenges of international research. FINDINGS: International research is worth pursuing; however, it calls for scholarly attention to key methodological and ethical issues for its success. ORIGINALITY/VALUE: This commentary addresses salient issues pertaining to international research in one comprehensive account.

Adoption of evidence-based clinical innovations: the case of buprenorphine use by opioid treatment programs.

This article examines changes from 2005 to 2011 in the use of an evidence-based clinical innovation, buprenorphine use, among a nationally representative sample of opioid treatment programs and identifies characteristics associated with its adoption. We apply a model of the adoption of clinical innovations that focuses on the work needs and characteristics of staff; organizations' technical and social support for the innovation; local market dynamics and competition; and state policies governing the innovation. Results indicate that buprenorphine use increased 24% for detoxification and 47% for maintenance therapy between 2005 and 2011. Buprenorphine use was positively related to reliance on private insurance and availability of state subsidies to cover its cost and inversely related to the percentage of clients who injected opiates, county size, and local availability of methadone. The results indicate that financial incentives and market factors play important roles in opioid treatment programs' decisions to adopt evidence-based clinical innovations such as buprenorphine use.

Insights from a national survey into why substance abuse treatment units add prevention and outreach services.

BACKGROUND: Previous studies have found that even limited prevention-related interventions can affect health behaviors such as substance use and risky sex. Substance abuse treatment providers are ideal candidates to provide these services, but typically have little or no financial incentive to do so. The purpose of this study was therefore to explore why some substance abuse treatment units have added new prevention and outreach services. Based on an ecological framework of organizational strategy, three categories of predictors were tested: (1) environmental, (2) unit-level, and (3) unit leadership. RESULTS: A lagged cross-sectional logistic model of 450 outpatient substance abuse treatment units revealed that local per capita income, mental health center affiliation, and clinical supervisors' graduate degrees were positively associated with likelihood of adding prevention-related education and outreach services. Managed care contracts and methadone treatment were negatively associated with addition of these services. No hospital-affiliated agencies added prevention and outreach services during the study period. CONCLUSION: Findings supported the study's ecological perspective on organizational strategy, with factors at environmental, unit, and unit leadership levels associated with additions of prevention and outreach services. Among the significant predictors, ties to managed care payers and unit leadership graduate education emerge as potential leverage points for public policy. In the current sample, units with managed care contracts were less likely to add prevention and outreach services. This is not surprising, given managed care's emphasis on cost control. However, the association with this payment source suggests that public managed care programs might affects prevention and outreach differently through revised incentives. Specifically, government payers could explicitly compensate substance abuse treatment units in managed care contracts for prevention and outreach. The effects of supervisor graduate education on likelihood of adding new prevention and outreach programs suggests that leaders' education can affect organizational strategy. Foundation and government officials may encourage prevention and outreach by funding curricular enhancements to graduate degree programs demonstrating the importance of public goods. Overall, these findings suggest that both money and professional education affect substance abuse treatment unit additions of prevention and outreach services, as well as other factors less amenable to policy intervention.

Organizational survival in the outpatient substance abuse treatment sector, 1988-2000.

Substance abuse remains one of the most pressing health issues in the United States today, yet treatment supply continues to lag far behind need. Given the hostile environments treatment facilities face, their survival is a matter of pressing policy concern. Results from analyses of National Drug Abuse Treatment System Survey (NDATSS) data from 1988 through 2000 suggest that organizational attributes such as age, size, and client severity and resource dependencies such as reliance on government revenue affect survival, but their effects change over time. By the mid-1990s, director involvement in state and local policy making was positively associated with subsequent survival; later that decade, directors' professional credentials affected survival as well. Results also show that serving clients with multiple substance abuse problems became a survival liability by the late 1990s. Facilities that treat clients with multiple addictions may need additional financial support to serve these particularly vulnerable clients.

Factors associated with interorganizational relationships among outpatient drug treatment organizations 1990-2000.

OBJECTIVE: To identify the factors associated with drug abuse treatment center participation in interorganizational relationships (IORs). DATA SOURCES: Three nationally representative samples of outpatient drug abuse treatment units surveyed in 1990, 1995, and 1999/2000 as part of the National Drug Abuse Treatment System Survey (NDATSS), stratified by public/private status, treatment modality (methadone or nonmethadone), and organizational affiliation. STUDY DESIGN: Probit analyses on 647 lagged treatment center-year observations from the years 1990 to 1995 with outcomes in 1995 and 2000, respectively. Standard errors were adjusted for clustering of center-year observations within centers. PRINCIPAL FINDINGS: Centers with greater motivation to form IORs (e.g., as a result of client diversity or government revenue) were more likely to do so, as were centers with greater opportunities to form IORs (e.g., centers whose directors participated in policy making). CONCLUSIONS: Both motivating and enabling factors promoted the formation of IORs by drug abuse treatment centers. Managed care also played a distinct role, in this case appearing to undermine interorganizational cooperation. Because IORs can improve access to care and quality, policy makers should consider using both incentives and support such as management training to promote IOR formation.

Accessibility of addiction treatment: results from a national survey of outpatient substance abuse treatment organizations.

OBJECTIVES: This study examined organization-level characteristics associated with the accessibility of outpatient addiction treatment. METHODS: Program directors and clinical supervisors from a nationally representative panel of outpatient substance abuse treatment units in the United States were surveyed in 1990, 1995, and 2000. Accessibility was measured from clinical supervisors' reports of whether the treatment organization provided "treatment on demand" (an average wait time of 48 hours or less for treatment entry), and of whether the program turned away any patients. RESULTS: In multivariable logistic models, provision of "treatment on demand" increased two-fold from 1990 to 2000 (OR, 1.95; 95 percent CI, 1.5 to 2.6), while reports of turning patients away decreased nonsignificantly. Private for-profit units were twice as likely to provide "treatment on demand" (OR, 2.2; 95 percent CI, 1.3 to 3.6), but seven times more likely to turn patients away (OR, 7.4; 95 percent CI, 3.2 to 17.5) than public programs. Conversely, units that served more indigent populations were less likely to provide "treatment on demand" or to turn patients away. Methadone maintenance programs were also less likely to offer "treatment on demand" (OR, .65; 95 percent CI, .42 to .99), but more likely to turn patients away (OR, 2.4; 95 percent CI, 1.4 to 4.3). CONCLUSIONS: Although the provision of timely addiction treatment appears to have increased throughout the 1990s, accessibility problems persist in programs that care for indigent patients and in methadone maintenance programs.

Community referral sources and entry of treatment-naive clients into outpatient addiction treatment.

This study assessed the association of sources of client referral with enrollment of treatment-naive clients. Data from the 1995 (n = 618) and 2000 (n = 745) waves of the National Drug Abuse Treatment Survey (DATSS), a panel study of outpatient substance abuse treatment units (OSAT), were analyzed. Enrollment of treatment-naive clients was defined as the percentage of OSAT clients who entered treatment in the past 30 days with no prior treatment for substance abuse. A generalized estimating equation model simultaneously assessed the association of each referral source with the dependent variable, while controlling for potential confounding and accounting for correlation of unit-level responses over time. In the multivariable model, OSAT units with a greater proportion of treatment-naïve clients had received more referrals from employee assistance programs and the criminal justice system, and fewer referrals from mental health agencies. No effect of referral from medical or social service agencies was observed. These results highlight the role of coercive community institutions in treatment outreach efforts to persons in earlier phases of the "addiction career."

Trends in comprehensive service availability in outpatient drug abuse treatment.

Comprehensive medical and psychosocial services are essential to quality addiction treatment, but their availability declined in the 1980s. To determine whether this downward trend in the availability of comprehensive services continued in the 1990s, we analyzed data from a national panel study of outpatient substance abuse treatment units in 1990, 1995, and 2000. Response rates were greater than 85%. Regarding the availability of comprehensive services, including physical examinations, routine medical care, mental health services, financial counseling and employment counseling, administrators reported whether any substance abuse treatment client received the service in the past year. With the exception of physical examinations, whose reported availability increased from 1990 to 1995, and financial counseling, whose reported availability decreased during the same time, the reported availability of comprehensive services changed little during the 1990s. These findings highlight the continuing need to monitor access to comprehensive services and other quality markers in addiction treatment over time.