Vermont's "Hub & Spoke" Program Evaluation Published in Journal of Substance Abuse Treatment
Addiction to opioid substances such as heroin, morphine, and prescription pain medication continues to grow as a national public health crisis, demonstrating widespread economic, personal, political, and social consequences. In 2013, 1.9 million Americans were dependent on pain medication and 517,000 on heroin, with the former's use remaining nearly consistent or declining since 2002 and the latter's increasing. Mortality rates have mirrored these trends: In 2013, overdose deaths from opioid pain relievers declined slightly to 16,235 (from 16,651 in 2010) while heroin overdose deaths nearly tripled to 8,257 (from 3,036 in 2010).
According to a recently published article in the Journal of Substance Abuse Treatment(JSAT), the state of Vermont's experience follows this same pattern: "From 2011 to 2013, the number of Vermonters receiving treatment for prescription opiates and heroin increased from 2,864 (654 for heroin and 2,210 for prescription opiates) to 3,971 (1,375 for heroin and 2,596 for prescription opiates) – a 38.6% overall increase, with a 110.2% increase for heroin and a 17.5% increase for prescription opiates."
In response to the increasing rates of overdose deaths and demand for treatment, the JSAT article explores the questions of whether and how to expand access to statewide treatment services for opioid addiction – and, in particular, the treatment services' cost-effectiveness on overall healthcare and medical service expenditures. The article is co-authored by the Vermont Blueprint for Health's Mary Kate Mohlman, PhD, Beth Tanzman, MSW, and Craig Jones, MD, and by Onpoint's Karl Finison, MA, and Melanie Pinette, MEM.
To provide insight, evidence, and a systemic response to Vermont's public health emergency, the study uses the state's all-payer claims database – the Vermont Health Care Uniform Reporting and Evaluation System (VHCURES) – to examine Vermont's Medicaid expenditures for opioid addiction treatment and other services from 2008 to 2013. The authors chose to focus on the Medicaid population since Medicaid beneficiaries were (and continue to be) at higher risk for substance abuse and overdose during the study period, maintaining a 21% share of all substance abuse expenditures – roughly $5 billion – as of 2009.
For Vermont's Medicaid population, the authors compare the healthcare expenditures between two groups with opioid addiction: (1) those receiving medication-assisted therapy (MAT), which includes the use of medications (i.e., methadone or buprenorphine) in combination with counseling and behavioral therapies and (2) those receiving non-medication treatment approaches (e.g., behavioral therapies alone). While MAT's effectiveness has been demonstrated in reducing opioid use, its treatment strategies come with higher direct costs than alternatives; it has yet to be determined whether those associated costs are offset by a reduction in patients' related healthcare expenditures.
The study's authors set out to explore that trade-off for Vermont's Medicaid population, finding that "the overall difference in annual average expenditures was lower for the MAT group, even with the cost of MAT." In other words, despite MAT's higher direct costs compared to non-MAT strategies, MAT patients had much lower healthcare expenditures with lower rates of inpatient admissions and outpatient hospital emergency department visits being two key factors in the difference.
In light of their findings and combined with MAT's widely-considered effectiveness in treatment retention and reduction in opioid use, the authors suggest that Vermont's expansion of MAT services for the Medicaid population "has the potential to produce better opioid addiction treatment results and lower overall health care costs compared to other approaches to opioid addition treatment." For state Medicaid leaders looking to fight the opioid epidemic, the study provides a compelling case to expand early support for expanding MAT services rather than solely relying on "time-limited medication" or psychosocial and abstinence interventions. Furthermore, the study serves as a baseline by which the Vermont Blueprint can evaluate its Hub & Spoke program, a component of Vermont's broader Health Home design, which is aimed at linking greater access to MAT with a network of primary and community resources.