We also found that every additional 100 patient-waived physician per 1,000,000 residents was associated with an increase in Medicaid-covered buprenorphine prescriptions by 0.20 per 1000 residents per quarter (row 3, column 5: 95% CI, 0.15–0.26), or a relative 20.2%. Given that the national average numbers of 100 patient-waived physicians was 22.34 per 1,000,000 residents, our estimate implies that a 10% increase (ie, 2.234 per 1,000,000 residents) in the number of 100 patient-waived physicians was associated with a 45.1% increase in buprenorphine prescriptions (20.2%×2.234). Changes in the availability of 30 patient-waived physicians, on the other hand, did not have a statistically discernable effect on Medicaid-covered buprenorphine prescriptions.
In addition to the estimated increases in buprenorphine prescriptions, we also found similar patterns in Medicaid spending on buprenorphine (Table 2). Compared with the pre-post spending growth in the nonexpansion and late-expansion states, the expansion states saw a higher growth in Medicaid buprenorphine spending (row 2, columns 5: $117.5; 95% CI, 23.1–211.9). Translating the absolute effect sizes into percentage changes, state implementation of Medicaid expansions in 2014 was associated with a 49.9% growth in Medicaid buprenorphine spending on a per 1000 resident basis, or total Medicaid spending on buprenorphine.
Furthermore, we found that every additional 100 patient-waived physician per 1,000,000 residents was associated with a spending growth of $33.1 per 1000 residents per quarter (row 3, columns 5: 95% CI, 22.6–43.7), or a relative 14.0%. Our estimate implies that a 10% increase in the availability of 100 patient-waived physicians associated with a 31.3% increase in buprenorphine spending on a per 1000 resident basis (14.0%×2.234). We also found a spending growth of $12.1 per 1000 residents per quarter (row 4, columns 5: 95% CI, −0.8 to 25.2) attributable to every additional 30 patient-waived physician per 1,000,000 residents, albeit only significant at the 0.10 level.
Our findings provide some of the first empirical evidence concerning the impact of Medicaid expansions under the ACA on the utilization of buprenorphine for medication-assisted treatment of opioid use disorder. We found that state implementation of the expansions was associated with a 70% increase in Medicaid-covered buprenorphine prescriptions, and a 50% increase in Medicaid spending on buprenorphine. The main findings were consistent with those from sensitivity analyses (please see Appendix Tables A7–A9, Supplemental Digital Content, http://links.lww.com/MLR/B346, for the sensitivity analysis results). Similar early effects of the ACA Medicaid expansions on access to substance use disorder treatment have been observed in Medicaid claims data in states such as Kentucky and experienced by physicians in Massachusetts and Maryland.29–31 As many expansion states such as Kentucky, New Hampshire, and New York start to implement legislative initiatives to facilitate access to Medicaid coverage and medication-assisted treatment among low-income people with opioid use disorder,32–35 we expect to see even more significant improvement in buprenorphine utilization in the future.
Our findings also suggest that the availability of DATA-waived physicians, particularly the 100 patient-waived physicians, is also associated with increases in Medicaid-covered buprenorphine prescriptions and spending. It is worth noting that including the availability of DATA-waived physicians into the main analyses reduced the effects of the ACA Medicaid expansions on buprenorphine prescriptions and buprenorphine spending by 38.9% (Appendix A5, Supplemental Digital Content, http://links.lww.com/MLR/B346, row 2: from 1.13 to 0.69 per 1000 residents per quarter) and 30.9% (Appendix A6, Supplemental Digital Content, http://links.lww.com/MLR/B346, row 2: from $167.5 to $117.5 per 1000 residents per quarter). These findings suggest that limited physician prescribing capacity may impose a constraint on the policy impact of Medicaid expansions. In other words, sufficient physician prescribing capacity is necessary for ensuring that Medicaid expansion achieves its full potential in improving buprenorphine utilization. On July 6, 2016, the Department of Health and Human Services released a final rule, effective on August 8, 2016, to raise the patient limit from 100 to 275 for DATA-waived physicians.36 As new enrollees in the expansion states may present Medicaid and healthcare system with additional needs for medication-assisted treatment, active physician participation in the provision of buprenorphine, coupled with an enabling policy environment, will help absorb the potential increase in treatment needs and address the ongoing opioid epidemic. Future research is needed to explore this interaction policy effect of physician prescribing capacity and Medicaid expansions on improving treatment access and reducing opioid use disorder.
In conclusion, our study uses timely, comprehensive Medicaid administrative data and provides some of the first empirical evidence that state implementation of Medicaid expansions may have significantly increased Medicaid-covered buprenorphine prescriptions and buprenorphine spending. Our findings suggest that Medicaid expansion has the potential to reduce the financial barriers to buprenorphine utilization and improve access to medication-assisted treatment of opioid use disorder. In this regard, physicians and policymakers should be mindful of the additional needs for medication-assisted treatment associated with Medicaid expansions and create a supportive environment to translate the potential increase in treatment needs into the meaningful improvement in buprenorphine utilization, which will be crucial in addressing the nation’s opioid epidemic.
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