Last month, Louisiana received a $24-million federal grant to combat the opioid epidemic[i]. This was welcome news after a budget that would have cut $648 million of state funds directed at hospitals, nursing homes, and residency programs was nearly approved. Nationwide, the federal government plans to spend nearly $5 billion dollars[ii] to combat the epidemic. While the figure is staggering, it pales in comparison to the detrimental impact opioid addiction has on the country’s economy.
In addition to taking the lives of over 40,000 people each year, most of whom are under the age of 55, Opioid Use Disorder (OUD) resulted in an estimated $500 billion in economic cost in 2015 alone[iii]. While the majority of this cost is due to early death, OUD results in decreased productivity, increased hospital costs, and higher rates of incarceration.
Physicians have often been the ones tasked with tackling this immense problem. After all, they hold the prescribing power for both the opioids that can lead to addiction and the medications that serve as treatment for OUD. But we need more than the physician’s pen.
In the past decade, there has been an increased emphasis on Value-Based Care (VBC), i.e. maximizing the quality of care while controlling its cost. Value-Based Payment (VBP) structures often take the form of bundled payments for an episode of care; for example, a single payment for the surgery, physical therapy, and follow up associated with a hip replacement. Other plans include performance incentives, penalties, and per-patient, per-month fees paid to providers[iv].
Naturally, the most common and expensive conditions are the target of these initiatives, e.g. heart disease, orthopedic surgeries, kidney disease. These conditions benefit from collaborative and close follow up of patients, which VBPs can encourage. In the same vein, prevention and treatment of OUD is an ideal VBC target. Currently, treatment for substance-use disorder is disjointed and most often provided on a fee-for-service basis. Physicians are reimbursed for treating substance use whether that treatment is successful or not. While no provider can force a patient into drug abstinence, we do not reward providers and organizations for taking extra steps to increase a patient’s chances. Integrated-care models that incorporate physicians, nurses, social workers and, most importantly, patients and their families are effective at managing many of the VBC target conditions[v]. VBP provide the financial investment for these partnerships.
So how could it work? A patient presents to a primary care clinic for a general checkup. Desperately wanting help, he reveals a struggle with opioid addiction. The physician immediately plugs the patient in with a multidisciplinary team comprised of behavioral-health specialists and medical providers. In addition to methadone or suboxone, the patient receives intensive behavioral therapy, home visits, and general medical care. An organization or provider then receives a Value-Based Payment with a bonus for a positive outcome.
Models like this are being tried in select states across the country. Massachusetts’ Medicaid program reimburses nurse care managers, who are responsible for coordinating all aspects of addiction treatment. In Rhode Island, weekly per-member bundled payments are provided to addiction treatment centers.[vi] Data collection is ongoing, but early reports are promising, with increased access and retention in treatment programs[vii].
Currently, these reimbursement models aren’t available in all states, and programs that target vulnerable populations, such as the uninsured or pregnant women, are limited. Building on the work pioneered by the likes of Michael Porter and Donald Berwick, the new era of Value-Based Care, with leaders such as Vinny Arora and Chris Moriates, should consider OUD a top priority for payment reform. An alarming study in 2016 found that 1.6 million years of life in the US were lost to opioids[viii]. VBPs are a proactive step to reduce this tremendous loss of life. Louisiana needs to use the new funding to emulate the successful VBP models in other states.
Neal Dixit is a fourth-year medical student at Tulane University School of Medicine going into internal medicine. In addition to staying active and exploring New Orleans, he spends his time thinking about how an increased emphasis on social determinants of health, healthcare value, and cutting-edge technology can be the solution to the country’s healthcare woes.