Study finds obstacles to alcohol, drug treatment higher for rural Americans

Rural Americans are less likely to initiate care for substance use disorders and to receive ongoing care compared with those who live in urban areas, according to a new study.

When they do access care, people who live in less populated areas are more likely to have to go outside their provider network to receive treatment, which comes with higher out-of-pocket costs, found a team of researchers at The Ohio State University College of Public Health. Their study appears in the journal Health Services Research.

“One thing that’s really striking is that we looked at sort of a best-case scenario for people with substance use disorders—care for people with private insurance tends to include high reimbursement rates and specialists are more likely to contract with those plans, meaning they have more robust provider networks,” said study lead author Eli Raver, an Ohio State doctoral student.

“If we find problems among this group, you know it’s going to be worse for everybody else.”

Looking at an employer-sponsored health care database, the research team examined data collected from 2016 through 2018 that included about 40 million adult patients each year.

Treatment rates for substance use disorders were low across the board—less than half of people received care. But the picture was worse for rural Americans.

Among the disparities found in the study:

• Rural patients experienced lower treatment initiation rates for disorders involving alcohol (37% vs. 38%), opioids (41% vs. 44%) and other drugs (38% vs. 40%) compared to those in urban areas.
• Rural patients were also less likely than urban patients to engage in ongoing treatment for alcohol (15% vs. 17%), opioids (21% vs. 23%) and other drugs (16% vs. 18%).
• More rural patients than urban patients received out-of-network initial treatment and continued treatment for drug use disorders other than alcohol and opioids. Rural patients were also more likely to pay higher rates for ongoing treatment for alcohol use disorders.

While substance use disorders and struggles finding and completing successful treatment are widespread concerns, matters are worse for those who live in rural areas, and this new research contributes more understanding about the obstacles people face, said Wendy Xu, the study’s senior author and an associate professor of health services management and policy at Ohio State.

“Rural areas are continuously plagued with a shortage of behavioral health providers and more limited health resources overall. These challenges are compounded by the fact that most insurance plans use managed care arrangements, some of which use highly limited provider networks,” Xu said.

One potential approach to tackling these problems could be the Collaborative Care Model, which has grown in popularity in recent years, she said, “This model allows primary care clinicians working with a behavioral health care manager, who often is not an advanced clinician, to treat substance use disorders in collaboration with a psychiatric consultant who doesn’t have to live and work in the area.”

In fact, the entire collaborative process of treatments, prescribing and ongoing care are typically delivered through virtual health appointments and billed through the patient’s primary care practice.

Raver said it’s important to note that while much of policymakers’ attention is focused on opioid use disorders, the disparities identified in this study exist across the spectrum of substance use disorders.

“A lot of policy focus has been on the opioid crisis, as it should be, but I think it’s interesting and troubling to see that, regardless of which substance we’re talking about, there is high out-of-network usage and low overall participation in care,” he said.

Study co-authors include Sheldon Retchin of Ohio State, Yiting Li of Nationwide Children’s Hospital and Andrew Carlo of Northwestern University.