Revenue Streams Associated with the Implementation of Medication-Assisted Treatment for Opioid Dependence

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1 Revenue Streams Associated with the Implementation of Medication-Assisted Treatment for Opioid Dependence Hannah K. Knudsen, Ph.D. Amanda J. Abraham, Ph.D. Lauren O Brien Paul M. Roman

2 Acknowledgements This research was supported by the National Institute on Drug Abuse (R01DA020757). Thank you to the research staff at the University of Georgia for collecting these data. Thank you to program administrators who participated.

3 Opioid Use Disorders (OUDs) in the US Nearly 2 million Americans met DSM-IV criteria for abuse/dependence in past year Majority = prescription opioids (1.7 million) Untreated OUDs has high medical, economic, and social costs Rise in overdose deaths since the mid- 1990s

4 Historical Context of Opioid Treatment in the US For 40 years, methadone maintenance treatment (MMT) was the primary type of medication-assisted treatment (MAT) for OUDs Dispensed in specialized clinics In 2000, just 9% of SUD facilities in the US were MMT clinics MMT a planned component in only 40% of all US opioid treatment admissions

5 Historical Context (cont.) Traditional drug-free SUD treatment programs also treat patients with OUDs Large national study of 763 treatment centers in (Ducharme et al., 2006) Average center caseload = 17% patients with primary diagnosis of OUDs

6 Expanding Options for MAT Naltrexone Tablets approved by FDA in 1984 for opioid dependence Long-acting depot formulation approved for OUDs in 2010 No special regulations related to prescribing, so could be prescribed by physicians in SUD clinics

7 Expanding Options for MAT (cont.) Buprenorphine Sublingual tablets approved by FDA in 2002; now available in sublingual films Physician must apply for X-license from DEA after meeting either training or credentialing requirements Unlike methadone, it can be prescribed in physician offices and non-mmt SUD programs

8 Literature on MAT in SUD Settings Emphasis on adoption (i.e., any use) of specific medications at the organizational-level Privately funded organizations (Knudsen et al., 2011a) Use methadone: 8% Use buprenorphine: 21% Use naltrexone: 22% Publicly funded organizations (Knudsen et al., 2011b) Use methadone: 9% Use buprenorphine: 24% Use naltrexone: 17%

9 Literature on MAT Implementation MAT implementation for OUDs in privately funded SUD treatment organizations (Knudsen et al., 2011) For buprenorphine adopters, mean implementation = 37% of OUD patients For methadone adopters, mean implementation = 41% of OUD patients For naltrexone adopters, mean implementation = 11% of OUD patients Mean MAT implementation = 34% OUD px in programs that had adopted 1 of 3 meds

10 Perspective on Implementation Observational research Not an implementation intervention Understanding implementation under natural conditions Focus on systems-level influences Whether funding sources are related to implementation of MAT for OUDs

11 Resource Dependence Theory Organizations are embedded within environments (Pfeffer, 1987) Decisions reflect attempts to manage relationships with external sources of resources Different types of funding as a potential driver of implementation

12 Research Questions To what extent is MAT for OUDs being implemented within treatment programs? Which revenue streams are associated with MAT implementation? Governmental funding Private insurance funding

13 Sample: NIDA s Clinical Trials Network CTN partners university-based nodes and community-based treatment centers Not a random sample Full range of treatment settings, including Outpatient Residential & therapeutic communities Hospital inpatient Opioid treatment programs/mmt (excluded because MAT implementation ~ 100%)

14 Sample: The CTN (cont.) Some centers are single sites, while other have multiple units/cost centers Data collected from multiple units if there are separate administrators with control over their unit s budget Used cluster command in Stata to produce robust standard errors that adjust for nesting of multiple units within a single organization

15 Data Collection Face-to-face interviewers conducted with administrators in Telephone screening identified 238 eligible treatment centers in the CTN Treatment structured outpatient, or Opioid treatment program (methadone) Response rate = 84.7% (n = 198) Analysis exclude 42 OTPs that offered no other levels of care

16 Defining Implementation of MAT for OUDs Measured adoption of buprenorphine, tablet naltrexone, and methadone Non-adopters for a given medication coded 0 for implementation Adopters asked percentage of patients with OUDs that receive each medication Depot naltrexone not FDA-approved for opioids in Summing implementation of three meds to yield overall MAT for OUDs

17 Measures of Revenue Streams Percentage of past-year revenues from: Medicaid Private insurance Criminal justice Federal block grant State government (non-block grant) Local/county government Questions were sent prior to interview to allow administrators to consult records

18 Control Variables Organizational structure Location in hospital Profit status Outpatient-only treatment services Workforce Number of physicians on staff Percentage counselors with master s degree Percentage counselors in recovery

19 Statistical Analysis Multiple imputation to address missing covariates ( ice in Stata 12) Negative binomial regression MAT measured as whole number (count) Can handle substantial number of 0 s Robust standard errors (clustering) Revenue streams are not independent Examine each separately, then with control variables if p <. 05

20 Organizational Characteristics % (N) or Mean (SD) Organizational Structure Hospital-based 12.0% (18) For-profit 8.7% (13) Outpatient-only treatment services 51.0% (76) Workforce Characteristics Number of physicians on staff 0.96 (1.42) % counselors with master s level degree (36.04) % counselors in recovery (34.04)

21 Heterogeneity in Revenue Streams

22 Implementation of MAT for OUDs Mean MAT implementation = 9.6% of OUD patients (SD = 24.1) Influenced by majority of centers (76%) not implementing MAT for any patients with OUDs Vast majority report treating patients with OUDs Only 1 CTP with no rx opioid or heroin patients Sub-set of MAT adopters yields higher implementation mean of 40.4% (SD = 34.9)

23 Significant Revenues Streams: Bivariate Models Medicaid (+) b =.02, SE =.01, p <.05 Criminal justice (-) b = -.06, SE =.02, p <.05 County government (-) b = -.02, SE =.01, p <.05

24 Non-Significant Revenues for MAT Implementation Federal block grant State government funding Private insurance (p =.08)

25 Multivariate Models of Implementation Medicaid revenues associated with MAT implementation after controlling for organizational characteristics SD in Medicaid 108% in expected count Criminal justice revenues negatively associated with MAT implementation SD in CJ 48% in expected count County funding not significant in multivariate model

26 Conclusions MAT implementation for OUDs is particularly low if non-adopters are included in the analysis Rate of implementation (40%) among adopters was similar to prior study of privately funded programs (34%) Medicaid was positively associated with implementation, while the association for criminal justice funding was negative

27 Limitations CTN programs are not a random sample Data are cross-sectional, so cannot establish causality Self-reported data by administrators (recall or desirability bias)

28 Directions for Future Research Impact of health care reform Changes to Medicaid, expanding insurance coverage Implications for MAT implementation? Physician decision-making How do physicians make decisions to prescribe MAT? What role does a patient s primary source of payment have on prescribing decisions?

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