• <div class="header-image" style="background-image: url(/live/image/gid/4/2957_V6N10_Header.rev.1542820788.jpg);">​</div><div class="header-background-color"/>

Treatment of Opioid Use Disorders: Significance of Medicaid Expansion and the Patient-Centered Opioid Addiction Treatment (P-COAT) Payment Model

November 10, 2018
The United States is experiencing a serious opioid epidemic and addressing this crisis should be a national health priority. In 2016, drug overdoses alone resulted in 63,632 American deaths, 66.4% of which involved prescription opioids, illicit opioids, or both. [1] This number will most likely continue to climb as the most recently available data shows opioid overdoses to have increased 30 percent from July 2016 through September 2017 in 45 states. [2] The Centers for Disease Control and Prevention estimates that the total economic cost of prescription opioid misuse in the United States is $78.5 billion a year, including the costs of healthcare, lost productivity, addiction treatment, and criminal justice involvement. [Ibid.] This epidemic began developing in the early 2000s and has now become the largest and fastest growing problem affecting public health, social welfare, and the US economy.  The epidemic is characterized by a move from the abuse of legally manufactured prescription opioids to the abuse of illegally manufactured “street” opioids such as heroin and illicitly-made fentanyl. [3] Evidence suggests that the supply-reduction efforts in the prescription of opioids, the natural tendency of addiction to more potent opioids, as well as a greater supply of cheap illicit opioids have all contributed to this new trend. [4]

Figure 1: Overdose deaths involving opioids, by type of opioid in the United States, 2000-2016

Figure 1: Overdose deaths involving opioids, by type of opioid in the United States, 2000-2016

In response to the opioid crisis, Secretary Price of the U.S. Department of Health and Human Services (HHS) announced the department’s strategy for fighting the opioid crisis. [5] HHS will be focusing its efforts on five major priorities: improving access to treatment and recovery services, promoting use of overdose-reversing drugs, strengthening our understanding of the epidemic through better public health surveillance, providing support for cutting-edge research on pain and addiction and advancing better practices for pain management. These priorities unveil the importance of intervention in an effort to reduce the abuse of both prescription and illicit opioids among users with varying addiction acuteness. An example of this in practice is the treatment for opioid use disorders (OUD), through a “demand-reduction” effort that helps users recuperate from opioid addiction and recover their health and social functioning. [6] Treatment of OUD involves detoxification and rehabilitation services, where detoxification stabilizes the patient by treating acute opioid withdrawal symptoms while rehabilitation engenders long-term recovery by administering behavioral health and support services after achieving stabilization. Services can be administered in various settings including outpatient, inpatient or residential locations, and may involve medication assisted treatment, with methadone or buprenorphine being the most effective treatments for OUD. These medications have more than doubled illicit opioid abstinence outcomes in randomized control trials, yet those in need (up to 80%) often fail to receive any treatment. [7] Barriers in availability and utilization account for some of this treatment gap. Barriers in availability include scarcity of licensed providers, limitations in patient capacity and strict regulation while barriers in utilization include the cost of treatment and limited health insurance coverage. [6]

 

Figure 2: State participation in CDC's Overdose Prevention Program

Figure 2: State participation in CDC's Overdose Prevention Program

 

Given that health insurance coverage is an obstacle for many OUD patients, theoretically, increasing health insurance coverage should reduce out-of-pocket treatment costs and, thus, lead to more utilization of services by patients. The Affordable Care Act (ACA), the most substantial expansion of health insurance since the passage of Medicare and Medicaid in 1965, was expected to narrow the treatment gap through regulatory changes and increases in insurance coverage. [8] This new regulation defines substance use disorder (SUD) services as one of ten essential health benefits that insurers have to cover, allowing variation of certain specific services by state. [9] Because of the ACA, Medicaid expansions became effective in 33 states and the District of Columbia, as of 2017.

In studying the role of health insurance coverage on OUD treatment utilization and availability by estimating the effect of Medicaid expansions under the ACA, Medicaid expansions have been found to significantly increase utilization of OUD services and treatments. [10] [11] Increases in opioid patient admissions to specialty treatment facilities rose by 18% in states with Medicaid expansion. [8] This OUD patient cohort increased by 113% without limiting admissions from patients with other forms of health insurance. Additionally, admissions to outpatient locales offering rehabilitation services involving medication assisted treatment increase considerably, while those from more involved and expensive services (e.g. detoxification) remained the same. Furthermore, there was greater utilization of OUD services in Medicaid expansion states that offered wide-ranging medication assisted treatment (MAT) coverage. In the case of availability, this study found more Medicaid acceptance and market entry among some MAT providers without a change in the range of offered services. There was 17 % increase in opioid treatment programs accepting Medicaid, thus improving MAT availability for the new enrollees, and maybe some previously enrolled Medicaid individuals, since OTPs are explicitly authorized to prescribe methadone and buprenorphine. As with the gains in utilization, gains in availability were greatest in states that allow Medicaid expansion and comprehensive coverage of MAT. This is one of a limited number of studies exploring how wide-ranging changes in the health insurance coverage markets can result in changes both on the demand and supply ends, thus pointing at Medicaid’s important role in addressing the opioid epidemic.

Figure 3: ACA Medicaid Expansion Reduced Share of Opioid-Related Hospitalizations in which Patient was uninsured

Figure 3: ACA Medicaid Expansion Reduced Share of Opioid-Related Hospitalizations in which Patient was uninsured


Given that only 33 states (including D.C.) have expanded Medicaid coverage thus far, a substantial number of low income patients are left without accessible MAT. [12] The American Society of Addiction Medicine (ASAM) and the American Medical Association (AMA) have announced an alternative payment model that may further assist in addressing opioid use disorder. [13] The new payment model, known as Patient-Centered Opioid Addiction Treatment (P-COAT), is designed to help patients with opioid use disorder lead more “satisfying, productive lives successfully managing their condition and reducing health care spending on costs associated with addiction, such as emergency department visits and hospitalizations.” [14] This new model is anticipated to increase patient utilization and access to treatments for OUD by providing financial support and broadening the coordinated administration of medical, psychological and social support services. Additionally, P-COAT is designed to promote office-based treatment in order to encourage coordination between multiple treatment providers thereby streamlining the process. Typically, payment for these services is separated, resulting in lack of comprehensive patient care. The P-COAT payment method is based on research showing that combining medication with psychological and social support is effective in treating patients with OUD. ASAM and the AMA are now seeking physician practices and insurers interested in pilot testing the new payment model.
In conclusion, there is strong evidence that Medicaid can play a significant role in addressing the opioid crisis. Many of the states that have declined Medicaid expansion have high rates of opioid abuse and may need to reconsider this policy stance. [15] Additionally, rejiggering payment models may help ensure patients get comprehensive medical care for long-term patient recovery.

 

Student Blog Disclaimer
  • The views expressed on the Student Blog are the author’s opinions and don’t necessarily represent the Penn Wharton Public Policy Initiative’s strategies, recommendations, or opinions.


References

 [1] [Online]. Available: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6090487/.
 [2] [Online]. Available: https://www.cbpp.org/research/health/medicaid-expansion-dramatically-increased-coverage-for-people-with-opioid-use.
 [3] [Online]. Available: https://www.cdc.gov/drugoverdose/pubs/index.html.
 [4] [Online]. Available: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5304419/.
 [5] [Online]. Available: https://www.drugabuse.gov/drugs-abuse/opioids/opioid-overdose-crisis.
 [6] [Online]. Available: https://www.sciencedirect.com/science/article/pii/S0167629617311530#bbib0070.
 [7] [Online]. Available: https://www.sciencedirect.com/science/article/pii/S0167629617311530?via%3Dihub.
 [8] [Online]. Available: https://www.cbpp.org/research/health/medicaid-expansion-dramatically-increased-coverage-for-people-with-opioid-use.
 [9] [Online]. Available: https://www.healthcare.gov/coverage/mental-health-substance-abuse-coverage/.
 [10] [Online]. Available: https://www.sciencedirect.com/science/article/pii/S0167629617311530#bbib0070.
 [11] [Online]. Available: https://www.cbpp.org/research/health/medicaid-expansion-dramatically-increased-coverage-for-people-with-opioid-use.
 [12] [Online]. Available: https://familiesusa.org/product/50-state-look-medicaid-expansion.
 [13] [Online]. Available: https://healthpayerintelligence.com/news/ama-promotes-alternative-payment-model-for-opioid-use-disorder.
  [14] [Online]. Available: https://www.ama-assn.org/asam-ama-announce-model-improve-treatment-opioid-use-disorder.
 [15] [Online]. Available: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5308192/.

PENN WHARTON PPI
RESOURCE SPOTLIGHT:

  • <h3>NOAA National Climatic Data Center</h3><p><img width="200" height="198" alt="" src="/live/image/gid/4/width/200/height/198/483_noaa_logo.rev.1407788692.jpg" class="lw_image lw_image483 lw_align_left" srcset="/live/image/scale/2x/gid/4/width/200/height/198/483_noaa_logo.rev.1407788692.jpg 2x, /live/image/scale/3x/gid/4/width/200/height/198/483_noaa_logo.rev.1407788692.jpg 3x" data-max-w="954" data-max-h="945"/>NOAA’s National Climatic Data Center (NCDC) is responsible for preserving, monitoring, assessing, and providing public access to the Nation’s treasure of <strong>climate and historical weather data and information</strong>.</p><p> Quick link to home page: <a href="http://www.ncdc.noaa.gov/" target="_blank">http://www.ncdc.noaa.gov/</a></p><p> Quick link to NCDC’s climate and weather datasets, products, and various web pages and resources: <a href="http://www.ncdc.noaa.gov/data-access/quick-links" target="_blank">http://www.ncdc.noaa.gov/data-access/quick-links</a></p><p> Quick link to Text & Map Search: <a href="http://www.ncdc.noaa.gov/cdo-web/" target="_blank">http://www.ncdc.noaa.gov/cdo-web/</a></p><p>See all <a href="/data-resources/">data and resources</a> »</p>
  • <h3>MapStats</h3><p> A feature of FedStats, MapStats allows users to search for <strong>state, county, city, congressional district, or Federal judicial district data</strong> (demographic, economic, and geographic).</p><p> Quick link: <a href="http://www.fedstats.gov/mapstats/" target="_blank">http://www.fedstats.gov/mapstats/</a></p><p>See all <a href="/data-resources/">data and resources</a> »</p>
  • <h3>The World Bank Data (U.S.)</h3><p><img width="130" height="118" alt="" src="/live/image/gid/4/width/130/height/118/484_world-bank-logo.rev.1407788945.jpg" class="lw_image lw_image484 lw_align_left" srcset="/live/image/scale/2x/gid/4/width/130/height/118/484_world-bank-logo.rev.1407788945.jpg 2x, /live/image/scale/3x/gid/4/width/130/height/118/484_world-bank-logo.rev.1407788945.jpg 3x" data-max-w="1406" data-max-h="1275"/>The <strong>World Bank</strong> provides World Development Indicators, Surveys, and data on Finances and Climate Change.</p><p> Quick link: <a href="http://data.worldbank.org/country/united-states" target="_blank">http://data.worldbank.org/country/united-states</a></p><p>See all <a href="/data-resources/">data and resources</a> »</p>
  • <h3>HUD State of the Cities Data Systems</h3><p><strong><img width="200" height="200" alt="" src="/live/image/gid/4/width/200/height/200/482_hud_logo.rev.1407788472.jpg" class="lw_image lw_image482 lw_align_left" srcset="/live/image/scale/2x/gid/4/width/200/height/200/482_hud_logo.rev.1407788472.jpg 2x, /live/image/scale/3x/gid/4/width/200/height/200/482_hud_logo.rev.1407788472.jpg 3x" data-max-w="612" data-max-h="613"/>The SOCDS provides data for individual Metropolitan Areas, Central Cities, and Suburbs.</strong> It is a portal for non-national data made available through a number of outside institutions (e.g. Census, BLS, FBI and others).</p><p> Quick link: <a href="http://www.huduser.org/portal/datasets/socds.html" target="_blank">http://www.huduser.org/portal/datasets/socds.html</a></p><p>See all <a href="/data-resources/">data and resources</a> »</p>
  • <h3>USDA Nutrition Assistance Data</h3><p><img width="180" height="124" alt="" src="/live/image/gid/4/width/180/height/124/485_usda_logo.rev.1407789238.jpg" class="lw_image lw_image485 lw_align_right" srcset="/live/image/scale/2x/gid/4/width/180/height/124/485_usda_logo.rev.1407789238.jpg 2x, /live/image/scale/3x/gid/4/width/180/height/124/485_usda_logo.rev.1407789238.jpg 3x" data-max-w="1233" data-max-h="850"/>Data and research regarding the following <strong>USDA Nutrition Assistance</strong> programs are available through this site:</p><ul><li>Supplemental Nutrition Assistance Program (SNAP) </li><li>Food Distribution Programs </li><li>School Meals </li><li>Women, Infants and Children </li></ul><p> Quick link: <a href="http://www.fns.usda.gov/data-and-statistics" target="_blank">http://www.fns.usda.gov/data-and-statistics</a></p><p>See all <a href="/data-resources/">data and resources</a> »</p>
  • <h3>The Penn World Table</h3><p> The Penn World Table provides purchasing power parity and national income accounts converted to international prices for 189 countries/territories for some or all of the years 1950-2010.</p><p><a href="https://pwt.sas.upenn.edu/php_site/pwt71/pwt71_form.php" target="_blank">Quick link.</a> </p><p>See all <a href="/data-resources/">data and resources</a> »</p>
  • <h3>National Bureau of Economic Research (Public Use Data Archive)</h3><p><img width="180" height="43" alt="" src="/live/image/gid/4/width/180/height/43/478_nber.rev.1407530465.jpg" class="lw_image lw_image478 lw_align_right" data-max-w="329" data-max-h="79"/>Founded in 1920, the <strong>National Bureau of Economic Research</strong> is a private, nonprofit, nonpartisan research organization dedicated to promoting a greater understanding of how the economy works. The NBER is committed to undertaking and disseminating unbiased economic research among public policymakers, business professionals, and the academic community.</p><p> Quick Link to <strong>Public Use Data Archive</strong>: <a href="http://www.nber.org/data/" target="_blank">http://www.nber.org/data/</a></p><p>See all <a href="/data-resources/">data and resources</a> »</p>
  • <h3>Federal Reserve Economic Data (FRED®)</h3><p><strong><img width="180" height="79" alt="" src="/live/image/gid/4/width/180/height/79/481_fred-logo.rev.1407788243.jpg" class="lw_image lw_image481 lw_align_right" data-max-w="222" data-max-h="97"/>An online database consisting of more than 72,000 economic data time series from 54 national, international, public, and private sources.</strong> FRED®, created and maintained by Research Department at the Federal Reserve Bank of St. Louis, goes far beyond simply providing data: It combines data with a powerful mix of tools that help the user understand, interact with, display, and disseminate the data.</p><p> Quick link to data page: <a href="http://research.stlouisfed.org/fred2/tags/series" target="_blank">http://research.stlouisfed.org/fred2/tags/series</a></p><p>See all <a href="/data-resources/">data and resources</a> »</p>
  • <h3>Internal Revenue Service: Tax Statistics</h3><p><img width="155" height="200" alt="" src="/live/image/gid/4/width/155/height/200/486_irs_logo.rev.1407789424.jpg" class="lw_image lw_image486 lw_align_left" srcset="/live/image/scale/2x/gid/4/width/155/height/200/486_irs_logo.rev.1407789424.jpg 2x" data-max-w="463" data-max-h="596"/>Find statistics on business tax, individual tax, charitable and exempt organizations, IRS operations and budget, and income (SOI), as well as statistics by form, products, publications, papers, and other IRS data.</p><p> Quick link to <strong>Tax Statistics, where you will find a wide range of tables, articles, and data</strong> that describe and measure elements of the U.S. tax system: <a href="http://www.irs.gov/uac/Tax-Stats-2" target="_blank">http://www.irs.gov/uac/Tax-Stats-2</a></p><p>See all <a href="/data-resources/">data and resources</a> »</p>
  • <h3>Congressional Budget Office</h3><p><img width="180" height="180" alt="" src="/live/image/gid/4/width/180/height/180/380_cbo-logo.rev.1406822035.jpg" class="lw_image lw_image380 lw_align_right" data-max-w="180" data-max-h="180"/>Since its founding in 1974, the Congressional Budget Office (CBO) has produced independent analyses of budgetary and economic issues to support the Congressional budget process.</p><p> The agency is strictly nonpartisan and conducts objective, impartial analysis, which is evident in each of the dozens of reports and hundreds of cost estimates that its economists and policy analysts produce each year. CBO does not make policy recommendations, and each report and cost estimate discloses the agency’s assumptions and methodologies. <strong>CBO provides budgetary and economic information in a variety of ways and at various points in the legislative process.</strong> Products include baseline budget projections and economic forecasts, analysis of the President’s budget, cost estimates, analysis of federal mandates, working papers, and more.</p><p> Quick link to Products page: <a href="http://www.cbo.gov/about/our-products" target="_blank">http://www.cbo.gov/about/our-products</a></p><p> Quick link to Topics: <a href="http://www.cbo.gov/topics" target="_blank">http://www.cbo.gov/topics</a></p><p>See all <a href="/data-resources/">data and resources</a> »</p>
  • <h3>National Center for Education Statistics</h3><p><strong><img width="400" height="80" alt="" src="/live/image/gid/4/width/400/height/80/479_nces.rev.1407787656.jpg" class="lw_image lw_image479 lw_align_right" data-max-w="400" data-max-h="80"/>The National Center for Education Statistics (NCES) is the primary federal entity for collecting and analyzing data related to education in the U.S. and other nations.</strong> NCES is located within the U.S. Department of Education and the Institute of Education Sciences. NCES has an extensive Statistical Standards Program that consults and advises on methodological and statistical aspects involved in the design, collection, and analysis of data collections in the Center. To learn more about the NCES, <a href="http://nces.ed.gov/about/" target="_blank">click here</a>.</p><p> Quick link to NCES Data Tools: <a href="http://nces.ed.gov/datatools/index.asp?DataToolSectionID=4" target="_blank">http://nces.ed.gov/datatools/index.asp?DataToolSectionID=4</a></p><p> Quick link to Quick Tables and Figures: <a href="http://nces.ed.gov/quicktables/" target="_blank">http://nces.ed.gov/quicktables/</a></p><p> Quick link to NCES Fast Facts (Note: The primary purpose of the Fast Facts website is to provide users with concise information on a range of educational issues, from early childhood to adult learning.): <a href="http://nces.ed.gov/fastfacts/" target="_blank">http://nces.ed.gov/fastfacts/#</a></p><p>See all <a href="/data-resources/">data and resources</a> »</p>
  • <h3>Federal Aviation Administration: Accident & Incident Data</h3><p><img width="100" height="100" alt="" src="/live/image/gid/4/width/100/height/100/80_faa-logo.rev.1402681347.jpg" class="lw_image lw_image80 lw_align_left" srcset="/live/image/scale/2x/gid/4/width/100/height/100/80_faa-logo.rev.1402681347.jpg 2x, /live/image/scale/3x/gid/4/width/100/height/100/80_faa-logo.rev.1402681347.jpg 3x" data-max-w="550" data-max-h="550"/>The NTSB issues an accident report following each investigation. These reports are available online for reports issued since 1996, with older reports coming online soon. The reports listing is sortable by the event date, report date, city, and state.</p><p> Quick link: <a href="http://www.faa.gov/data_research/accident_incident/" target="_blank">http://www.faa.gov/data_research/accident_incident/</a></p><p>See all <a href="/data-resources/">data and resources</a> »</p>