Access to Office-Based Buprenorphine Treatment in Areas With High Rates of Opioid-Related Mortality: An Audit Study

Abstract

Background: Improving access to treatment for opioid use disorder is a national priority, but little is known about the barriers encountered by patients seeking buprenorphine-naloxone ("buprenorphine") treatment.

Objective: To assess real-world access to buprenorphine treatment for uninsured or Medicaid-covered patients reporting current heroin use.

Design: Audit survey ("secret shopper" study).

Setting: 6 U.S. jurisdictions with a high burden of opioid-related mortality (Massachusetts, Maryland, New Hampshire, West Virginia, Ohio, and the District of Columbia).

Participants: From July to November 2018, callers contacted 546 publicly listed buprenorphine prescribers twice, posing as uninsured or Medicaid-covered patients seeking buprenorphine treatment.

Measurements: Rates of new appointments offered, whether buprenorphine prescription was possible at the first visit, and wait times.

Results: Among 1092 contacts with 546 clinicians, schedulers were reached for 849 calls (78% response rate). Clinicians offered new appointments to 54% of Medicaid contacts and 62% of uninsured-self-pay contacts, whereas 27% of Medicaid and 41% of uninsured-self-pay contacts were offered an appointment with the possibility of buprenorphine prescription at the first visit. The median wait time to the first appointment was 6 days (interquartile range [IQR], 2 to 10 days) for Medicaid contacts and 5 days (IQR, 1 to 9 days) for uninsured-self-pay contacts. These wait times were similar regardless of clinician type or payer status. The median wait time from first contact to possible buprenorphine induction was 8 days (IQR, 4 to 15 days) for Medicaid and 7 days (IQR, 3 to 14 days) for uninsured-self-pay contacts.

Limitation: The survey sample included only publicly listed buprenorphine prescribers.

Conclusion: Many buprenorphine prescribers did not offer new appointments or rapid buprenorphine access to callers reporting active heroin use, particularly those with Medicaid coverage. Nevertheless, wait times were not long, implying that opportunities may exist to increase access by using the existing prescriber workforce.

Primary funding source: National Institute on Drug Abuse.

FIGURE. 1:. Cohort flow diagram.

* Total listed waivered clinician counts were obtained on 25 January 2018 for the physicians and 30 June 2018 for the physician assistants and nurse practitioners. † Clinicians who were eligible to be in our sample for telephone contact but were randomly not selected. ‡ Includes situations in which a real-world patient may have been able to get an appointment but the study patient could not, such as when personal identifying information beyond a date of birth and name (such as a Medicaid plan number) or voicemail was required to inquire about appointment availability. § Each clinician was called under 2 scenarios—a patient covered by Medicaid and an uninsured patient who was self-paying—represented by “contacts,” such that there are 2 contacts for each clinician. We were able to contact 380 of the 546 in-sample clinicians twice, once by the Medicaid-insured caller and once by the uninsured–self-pay caller, and 89 clinics by only 1 of the callers (52 Medicaid, 37 uninsured–self-pay).