Closing the Care Continuity Gap in Substance Use Disorder
August 31, 2026
An actuarial view of $569 million in ACA marketplace SUD spending
Today, August 31, 2026, is International Overdose Awareness Day—a time to remember the lives lost to overdose, to support people affected by substance use, and to advance action that saves lives. In recognition of this day, Sober Sidekick and Wakely Consulting Group, an HMA Company, are releasing this new report to help strengthen the continuum of substance use disorder (SUD) care.
Health plans spend far more on acute stabilization and short-cycle services than on services that support sustained recovery, according to a joint analysis by Sober Sidekick and Wakely Consulting Group, an HMA Company.
The brief examines $569 million in allowed costs for approximately 150,000 Affordable Care Act (ACA) Marketplace members with a primary SUD diagnosis during benefit year 2023.
Key findings
- For every $1 spent on sustained recovery services, $3.64 was spent on acute stabilization and short-cycle services.
- Acute stabilization and short-cycle care represented 51.5% of analyzed spending, or approximately $293 million.
- Sustained recovery services represented 14.1% of analyzed spending, or approximately $80.4 million.
- Emergency department (ED) utilization accounted for the largest single concentration of spending, totaling $127.9 million across six billing codes.
- No sustained recovery service appeared among the 11 highest spend billing codes; the first appeared at rank 12.
- Medically assisted treatment (MAT) accounted for approximately 1.6% of SUD-primary spending in the dataset.
- Members using acute stabilization services averaged $5,577 in annual allowed costs, compared with $3,506 for members using sustained recovery services.
- Redirecting a portion of spending toward recovery sustaining services represents an estimated opportunity of approximately $2,071 per member.
The $2,071 figure is a planning estimate, not a guaranteed savings projection. Results are sensitive to local market conditions, member characteristics, benefit design, provider capacity, and claims experience.
Why this matters
EDs, detoxification, ambulance services, and residential care are often clinically necessary and can be lifesaving. The analysis does not recommend reducing access to these services.
Instead, it identifies a care continuity gap—the period before and after an acute event when members may not receive timely follow-up, MAT treatment, case management, psychotherapy, or ongoing peer support.
Closing that gap may help health plans move from episodic crisis response toward a more continuous model of SUD care.
What this brief examines
Wakely actuaries and HMA SUD clinical experts classified 200 Healthcare Common Procedure Coding System codes according to their relationship to sustained recovery. The framework considered:
- Strength of clinical evidence for SUD outcomes
- Cost-effectiveness reported in the literature
- Whether a service addresses upstream prevention or downstream consequence
- Contribution to long-term, stable recovery
The analysis grouped services into highest-value, high-value, mid-value, low-value, and lowest-value tiers. Mid-value services represented 34.4% of analyzed spending and were excluded from the headline 3.64:1 ratio because their relationship to long-term recovery was considered context dependent.
Implications for health plans
The findings point to several opportunities for payer and provider organizations:
- Identify members at key inflection points, including ED visits, detoxification, residential discharge, and missed follow-up
- Improve initiation and retention of medication-assisted treatment
- Connect members with peer support and case management between clinical appointments
- Monitor engagement patterns to identify potential disengagement earlier
- Explore value-based arrangements tied to treatment initiation, treatment engagement, post-ED follow-up, post-discharge follow-up, and pharmacotherapy for opioid use disorder
Frequently asked questions
What is the care continuity gap in SUD?
The care continuity gap is the period between acute stabilization and ongoing recovery support. It can occur after an ED visit, detoxification episode, residential discharge, or between monthly outpatient appointments.
What is the 3.64:1 finding?
For every $1 of analyzed SUD-primary spending on sustained recovery services, $3.64 was spent on acute stabilization and short-cycle services. The ratio compares low- and lowest-value tiers with high- and highest-value tiers; mid-value services were excluded.
What population was studied?
The analysis examined approximately 150,000 ACA marketplace lives with a primary SUD diagnosis during benefit year 2023, using $569 million in allowed costs from the Wakely ACA Database.
Does the report recommend reducing emergency or detoxification care?
No. Acute services can be clinically necessary and lifesaving. The report focuses on improving the connection between crisis services and sustained recovery.
Is the estimated $2,071 opportunity guaranteed savings?
No. It is a planning estimate based on observed differences in annual allowed costs between members using acute stabilization services and those using sustained recovery services. Actual results will vary by market and population.
Who produced the analysis?
The brief was produced jointly by Sober Sidekick and Wakely Consulting Group, an HMA Company. Wakely actuaries and HMA SUD clinical experts developed the recovery value classification framework.
Download Closing the Care Continuity Gap in SUD: An Actuarial View of $569M in ACA Marketplace SUD Spending to review the methodology, service classifications, claims distribution, implications for value-based payment, supporting evidence, and modeling disclosures.
