Clinician-Level Variation in MAUD Prescribing: The Role of Behavioral Health Experience

Less than 10% of Medicaid patients diagnosed with AUD in the USA received medication treatment for AUD (MAUD), despite its proven clinical effectiveness. Documenting clinician MAUD prescribing patterns can suggest solutions. Do clinicians with behavioral health (BH) experience have higher rates of MAUD prescribing in a Medicaid program in a state with a low supply of clinicians? This cross-sectional study used Nevada Medicaid professional and pharmacy claims data (2016-2019) to identify 7003 clinicians who prescribed to patients with alcohol use disorder (AUD). BH experience (exposure) was determined by (1) BH specialty from taxonomy, (2) BH patient volume above the median number of BH patients (n = 15), and (3) buprenorphine prescribing during the study period. Logistic regressions estimated adjusted odds ratios (aORs) for any prescribing, controlling for clinician characteristics. Zero-inflated negative binomial regressions estimated incidence rate ratios for the number of MAUD-prescribed patients and MAUD prescriptions. Only 8% (n = 541) of the study cohort prescribed MAUD. Clinicians with BH experience had higher odds of prescribing MAUD: those with BH specialty versus primary care (aOR 7.6, 95% CI 5.8-9.9), those who prescribed buprenorphine versus those who did not (aOR 3.9, 95% CI 2.9-5.3), and those with high versus low BH patient volume (aOR 6.1, 95% CI 4.4-8.4). Clinicians with BH experience had significantly higher counts of MAUD-prescribed patients and MAUD prescriptions than other clinicians. Amid MAUD underuse, clinicians with BH experience were instrumental MAUD prescribers for Nevada's Medicaid population. Expanding BH and primary care integration/colocation, increasing the BH workforce, and providing additional BH training in primary care could improve MAUD access.