Despite steep increases in prescription opioid overdose deaths among older adults, the topic of Medicare coverage for opioid use disorder (OUD) treatment has received considerably less attention than trends in Medicaid and private insurance coverage. A report published in this month's issue of Health Affairs illustrates a wide gap in availability of evidence-based treatment for OUD for Medicare beneficiaries.
Using 2007-2016 data from the National Survey of Substance Abuse Treatment Services (N-SSATS) and the Medicare Geographic Variation Public Use File, researchers found that only 13.8% of specialty addiction treatment programs in 2016 accepted Medicare and offered either buprenorphine or injectable naltrexone treatment for OUD. Furthermore, when the researchers excluded from the data those specialty programs that offered buprenorphine only for detoxification and not for extended treatment, the percentage dropped from 13.8% to 12.8%.
Moreover, the study's lead author tells Behavioral Healthcare Executive, there is evidence that the gap between Medicare and other coverage has continued to grow more recently.
Comparing 2016 and 2018 data, the percentage of non-OTP (opioid treatment program) specialty programs that accept Medicare is actually declining while a growing number are accepting Medicaid and private insurance, says Samantha J. Harris, a doctoral candidate in the Department of Public Administration and Policy at the University of Georgia School of Public and International Affairs. Until a recent change in federal law, Medicare did not cover methadone and other treatment services delivered in OTPs.
The percentage of non-OTP programs accepting Medicare dropped from 36.4% in 2016 to 35.2% in 2018, while the percentages of non-OTP programs accepting Medicaid and private insurance are in the 60s and 70s, respectively.
“Historically we've overlooked older adults and substance use disorder,” Harris says.
She adds, however, that there has been a slight overall increase between 2016 and 2018 in Medicare beneficiaries' access to medications for OUD, from 13.8% to 16.4%.
Harris and colleagues found that Medicare beneficiaries' access to evidence-based treatment for OUD was substantially more limited than that of Medicaid and private insurance recipients in 2016, with 24.8% and 28.6% of the specialty programs that accepted those forms of insurance offering an approved medication treatment.
Access also was particularly limited in non-urban areas, as nearly two-thirds of programs that accepted Medicare and offered a medication treatment for OUD were in urban communities. Access to Medicare coverage and evidence-based treatment was less likely in private for-profit and nonprofit treatment programs than in public programs. The Northeast outpaced other regions in the presence of specialty programs accepting Medicare and offering an approved medication treatment.
The shortages of effective treatment options for Medicare beneficiaries reflects barriers in coverage for the publicly insured in general, Harris believes. Some specialty programs may see the Medicare population as a particularly complex group to treat, in part because of the host of comorbid conditions that many older adults face, she says.
Some potential strategies for narrowing the service gap, particularly in more remote communities, include wider use of nurse practitioner and physician assistant services for buprenorphine prescribing, as well as greater application of OUD treatment services through telehealth and at federally qualified health centers, Harris says.