The overarching goal of this project is to utilize 2018/2019 Medicaid, Medicare and commercial insurance claims data to assess the level of Screening, Brief Intervention and Referral to Treatment (SBIRT) penetration across rural and urban counties as well as healthcare settings and provider types in the U.S. In addition, this analysis will allow for an initial comparison of SBIRT diffusion in current or previously funded Substance Abuse and Mental Health Services Administration (SAMHSA) demonstration project states as compared to states that have never received SAMHSA SBIRT funding. County-level overdose and hospital admission rates will be compared across the same years as a proxy for community need.

The study will test the following hypotheses:

1. SBIRT penetration varies in rural vs. urban settings.
2. SBIRT penetration varies based on states that have expanded Medicaid, experienced high rates of overdose death or substance-related hospital admissions, received Federal block grant funding, and/or received SAMHSA SBIRT demonstration-project funding.
3. SBIRT penetration varies by healthcare setting and provider type.

To test the above hypotheses and evaluate overall SBIRT usage in both rural and urban U.S. counties, the center will utilize cross-sectional data from 2018/2019 Medicare, Medicaid and Commercial claims. Identification of patient services related to SBIRT screening will be based on the following Healthcare Common Procedure Coding System (HCPCS) or Current Procedural Terminology (CPT) codes:

• H0049 (HCPCS code) – alcohol and/or drug screening
• H0050 (HCPCS code) – alcohol and/or drug screening, brief intervention, per 15 minutes
• G0396 (HCPCS code) – alcohol and/or substance (other than tobacco) abuse structured assessment and brief intervention, 15 to 30 minutes
• G0397 (HCPCS code) - alcohol and/or substance (other than tobacco) abuse structured assessment and brief intervention, > 30 minutes
• 99408 (CPT code) – alcohol and/or substance abuse structured screening and brief intervention services, 15 to 30 minutes
• 99409 (CPT code) – alcohol and/or substance abuse structured screening and brief intervention services, greater than 30 minutes

Provider and patient level analytical files will be constructed for the study population (patients that received SBIRT services) by aggregating claims data and merging with other datasets: patient enrollment files, Area Health Resources Files, National Plan and Provider Enumeration System National Provider Identifier file to include but not limited to the following variables for stratification in the exploratory data analysis: patient characteristics such as age, gender, socioeconomic status, etc., patient Substance Use Disorder (SUD) diagnosis codes, any SUD treatment received after first SBIRT intervention (alcohol and drug treatment HCPCS codes H0001-H0030), inpatient admissions, patient and provider ZIP code, Rural-Urban Commuting Area code, type of provider (e.g. Doctor or facility), state and region.

Summary statistics that focus on the SBIRT penetration by 1) Rural vs. Urban, 2) Medicaid expansion state, 3) healthcare setting and provider type will be examined first. Further analysis can then divide SUD cases by alcohol abuse and dependence, opioid abuse and dependence, and other drug abuse and dependence, to provide initial interpretation of the effects of the SBIRT intervention.

Findings will elucidate practice- and system-level correlates of SBIRT adoption in rural compared to urban settings which may be useful for identifying barriers and facilitators to adoption. Furthermore, when SBIRT proficient rural healthcare settings and providers are identified, policies and procedures can be disseminated to other rural practices.