How Health Care Payers Can Help Stem the Opioid Crisis

Public and private health care plans and others responsible for paying for health care costs—collectively known as payers—can and must play a pivotal role in improving how the U.S. health care system treats substance use disorders (SUD), according to John O’Brien, a veteran policymaker and consultant who has joined The Pew Charitable Trusts as a distinguished adviser.

In his career, O’Brien has partnered with a range of public and private stakeholders and seen attitudes about these diseases, as well as approaches to care, evolve for the better. As a consultant for the Centers for Medicare & Medicaid Services (CMS) and the Substance Abuse and Mental Health Services Administration (SAMHSA), he has helped Medicaid agencies finance treatment, collaborate with provider networks, and reconsider how they and other payers measure success when tackling these chronic conditions. His experiences implementing policies at the local, state, and federal levels have taught him that payers are integral to curbing the nation’s opioid crisis.

In his adviser role, he provides counsel for Pew’s work on substance use prevention and treatment and recently talked about his experiences in this field.

Q: You’ve had a long career focused on improving behavioral health and substance use disorder treatment. How are you working to tackle the opioid crisis?  

A: The best place to tackle it is with the payers, especially to improve their knowledge of the disease. For many years, health plans didn’t have to pay attention to SUD, or they did so on a very limited basis. As I and many others helped them understand that these conditions truly are diseases, they began to look at them differently. They looked at the associated costs and realized they needed to modernize their approach to covering SUD.

This is what I do: I help payers modernize. In this case, modernization means recognizing that caring for SUD includes a continuum of services—from early intervention to acute care to housing supports—and there is no “one size fits all.” Payers need to make services available, no matter what level of disease acuity a person presents with. And payers need to place a heavier emphasis on evidence-based practices and recovery supports, because there is often a cliff after treatment where people find themselves needing everything from support groups to recovery coaches to truly get better.

So the strategy is to get payers’ minds wrapped around what they need to do and help them see if what they’re doing is making a difference.

Q: When it comes to combating this serious public health problem, what works? What doesn’t?

A: There are a few practices we can point to as the gold standard in terms of research and data. For instance, we know screening, brief intervention, and referral to treatment works well for alcohol use disorder (AUD) and risky drinking.

When it comes to opioid use disorder (OUD), we know that medication-assisted treatment (MAT) works. MAT shows phenomenal results, both in terms of individuals stopping their opioid use and seeing health improvements, which reduces their health care costs and makes payers happy. Research also shows that individuals have good quality of life post-MAT. Some other therapies, such as cognitive behavioral therapy and motivational interviewing, also work well.

But we have to consider what works best for different types of SUD. Sometimes the health care field tries to apply the same treatment practice to all patients, with limited success.  And understanding what doesn’t work is trickier. We don’t have enough research on a lot of other services, so there isn’t data to determine if those interventions are effective or not.

But we hope that will change. In 2015, when state Medicaid agencies were granted more flexibility in their approaches to prevent and treat SUD, CMS asked them to use a variety of performance measures along the care continuum so the agency could gather data on hundreds of thousands of individuals. I’m hoping that five years from now, we will be able to see which state interventions were more or less effective.

Q: What are the biggest issues that people struggling with OUD face?

A: Access to MAT is a big struggle. Right now, to get a medication like buprenorphine, patients need a provider who is registered with the Drug Enforcement Administration and who has gone through trainings to prescribe it. This creates a burden for both the patient and the provider.

Payers have made a concerted effort to increase the number of these “waivered” prescribers in their networks, and SAMHSA made it easier by allowing physician assistants and nurse practitioners to prescribe. So the good news is that there are more options out there, but barriers remain. It’s not easy to become waivered. It’s time-consuming, and at the end of the day, providers won’t get paid much more from prescribing [buprenorphine].  

Some payers are developing incentives for providers to get and stay waivered, such as bonuses, or team-based approaches that lift the administrative onus from doctors. And in their contracts with providers, payers are requiring that practices have a MAT prescriber or that they provide referrals to one. Payers are getting very prescriptive about what those agreements look like—as in, “Show me your policies and procedures, and show me that providers and referrals exist.” Provider practices shouldn’t have to add new staff but can get existing eligible staff waivered.

Finally, stigma continues to be a problem. Some people still believe MAT is just swapping an illegal substance with a legal substance. And some primary care providers don’t want to serve patients with SUD, though in reality, they probably already are.  

Q: Where should policymakers be focusing their efforts? What strategies will have the most impact on patient outcomes? 

A: Policymakers have yet to pay sufficient attention to the intersection of physical and behavioral health.  In the past, payers would say they were working to integrate behavioral health providers and medical providers in practice settings so that someone diagnosed with an SUD could get treatment on demand without having to go to a residential treatment program. That’s great, but people with SUD have a variety of chronic diseases, and we haven’t been paying enough attention to comorbidities. Eighty-five percent of people with AUD have an additional medical condition, some obvious but some not. For example, almost 20 percent of people with AUD have arthritis, and 10 percent have asthma, COPD (chronic obstructive pulmonary disease), or chronic pain. These diseases and conditions occur less frequently in people without SUD.

Policymakers also need to encourage better access to MAT. States should not declare victory if they’ve doubled or even tripled their number of buprenorphine prescribers, because those numbers were so low to begin with. They must do a better job determining how many health care providers are required to adequately address the need.

The third issue is around housing. Most policymakers are focused on physical health and SUD and feel outside their comfort zone when asked to think about anything beyond that. But housing and employment matter, especially for people with chronic conditions. Thankfully, more employers and Medicaid agencies are looking at social determinants of health—which include housing and employment—as they relate to patient outcomes and recovery.

So policymakers should pay attention to these three issues over the next year, which were reinforced in the SUPPORT for Patients and Communities Act signed by President Trump in October. Congress gave states a huge opportunity, and now it’s up to states to follow through.