Blog Post

Primary care's next high-return opportunity: Substance use disorder treatment

December 20, 2018

    Substance use disorder (SUD) is a public health crisis with enormous cost. There were over 63,000 overdose deaths in 2016, and addiction costs from health care, criminal justice, and productivity loss amount to $700 billion annually. Despite these costs and the fact that SUD treatment is an essential health benefit under the Affordable Care Act, only one-in-five patients with SUD receives any form of treatment.

    One of the key reasons is that SUD has historically been perceived as a social or criminal problem, disconnecting treatment from health care. Without dedicated preventive care and early treatments, EDs bear the burden. SUD-related ED use increased 37% between 2006 and 2013. However, the reality is that SUD is a chronic condition, just like diabetes or CHF, so we should treat it like one.

    Medication-assisted therapy highly effective but underutilized

    There's rigorous evidence suggesting that medication-assisted treatment (MAT) is highly effective and can significantly reduce the burden on individuals and the health system. It combines nondrug therapies (e.g., cognitive behavioral therapy) and FDA-approved medications (e.g., methadone, buprenorphine). MAT has been shown to reduce relapse and medical costs, as well as decrease mortality risk 40% to 60% among opioid-overdose survivors. Nevertheless, only three-in-10 overdose survivors receive MAT.

    MAT is primary care's next high-impact, high-return opportunity

    Between 3% and 26% of primary care patients use illicit substances. Thus, just as with any other chronic condition, identification, intervention, and treatment must start in primary care. Treating SUD in primary care increases access, improves outcomes, supports relapse prevention, reduces stigma, and enables holistic treatment of SUD and non-SUD conditions.

    There are currently a number of barriers to providing MAT in primary care, including:

    • Stigma or discomfort among providers;
    • Lack of addiction specialists; and
    • Upfront costs and limited reimbursement.

    But new developments are chipping away at those barriers. For instance, payers are starting to remove prior authorization requirements and increase reimbursements, making it easier for health systems to deploy MAT in primary care. Here are three opportunities to increase access to MAT in primary care:

    1. Dedicate pharmacists to manage patients' pain

      Given the lack of addiction specialists, Geisinger Health System trained its embedded pharmacists on pain management alternatives and SUD patient identification. Today, pharmacists prescribe lower opioid dosages and use methadone more frequently among patients with SUDs. Within a year, Geisinger saw a 20% reduction in ED visits among those treated by trained pharmacists.

    2. Support PCPs with embedded specialized staff and centralized intensive care

      Vermont Medicaid uses a hub and spoke model to increase access to treatment across the state. They added RNs and master's–level licensed counselors into 77 primary care sites to help provide MAT to low- and moderate-acuity patients. These practices lean on nine central hubs to manage high-acuity patients and provide consults to their spokes when needed. At the hubs, patients receive care from board-certified addictionologists, staff physicians, advanced practice nurses, and registered and licensed practical nurses. Annual costs for MAT patients decreased by over $400 compared with a control group, when including MAT treatment costs. This difference grew to $2,400 when the analysis excluded addiction treatment costs.

    3. Deploy group visits to increase capacity and patient self-management

      To offer MAT in a cost-effective way, Open Door Community Health Centers—a group of FQHCs in Humboldt, California—offer group visits led by a drug counselor for six to 12 patients. Patients are called out one at a time for the nurse to conduct toxicology screenings and the prescribing physician to review the patient's MAT dosage and care plan. If needed, physicians can consult a psychiatrist. This group visit format enables the FQHCs to afford the counselor and nurse services, which are not billable.

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