Medicaid Funded Treatment Medicaid
Funded Treatment
for Opioid
p
Addiction: Should Buprenorphine be Rationed?
Funded by the Robert Wood Johnson Foundation’s
Foundation s
Substance Abuse Policy Research Program
Data access ggranted byy MassHealth
UMass Research Team
UMass Research Team




Robin Clark, Ph.D.
Mihail Samnaliev, Ph.D.
Mihail Samnaliev, Ph.D.
Jeff Baxter, M.D.
Gary Leung, Ph.D., M.P.H.
The team has no conflicts of
interest to disclose
Buprenorphine Points
Buprenorphine Points
 Introduced in 2003
 First opioid for addiction treatment that can First opioid for addiction treatment that can
be dispensed in an outpatient setting and taken without direct observation (Suboxone®)
taken without direct observation (Suboxone®)
 Clinical trials suggest somewhat greater effectiveness for methadone maintenance
 Fewer overdoses for Suboxone
Fewer overdoses for Suboxone®
See policy brief for more details:
http://saprp.org/knowledgeassets/knowledge_detail.cfm?KAID=13
Why we are interested in Buprenorphine & Medicaid?  Medicaid is a key source of buprenorphine
 Increasing concern about cost and diversion of Increasing concern about cost and diversion of
buprenorphine
 Ranks in the top 10 drug expenditures in many k i h
10 d
di
i
Medicaid programs
 Recent anecdotal reports of diversion
 Most states restrict access, some don’t offer it
M t t t
ti t
d ’t ff it
Buprenorphine expenditures in Massachusetts Medicaid
This is approximately ¼ of total MassHealth expenditures per person treated
Milllions
Average monthly expenditure for buprenorphine from 2003
for buprenorphine from 2003‐
2007 was more than $300 per person treated
p
MassHealth Buprenorphine RX RX
Payments
12
10
8
6
4
2
Buprenorphine expenditures are among the highest on the g
g
MassHealth drug list
0
2003
2004
2005
2006
2007
Research Questions
Research Questions
1. Does buprenorphine cost more than other forms of treatment?
2. Is it more risky?
3 Is there evidence that access to 3.
I h
id
h
buprenorphine should be restricted?
Study Design
Study Design
 Analyzed MassHealth claims for all beneficiaries with opioid dependence from p
p
2003 through 2007
 Tracked treatment, expenditures, relapse Tracked treatment expenditures relapse
indicators and deaths monthly
 Assigned beneficiaries to one of 4 groups each month: buprenorphine, methadone,
each month: buprenorphine, methadone, outpatient drug free, no treatment
Intent to Treat Analysis
Intent to Treat Analysis
 We combined the concept of treatment episodes with an intent‐to‐treat approach p
pp
similar to a clinical trial
 Expenditures/relapses/deaths followed for 6 Expenditures/relapses/deaths followed for 6
months after initiation of episode whether or not individuals stayed in/switched treatment
/
 Controlled for observable differences in Controlled for observable differences in
patients (multiple methods)
Measures
 Characteristics include demographics, enrollment categories and history, physical g
y, p y
and psychiatric co‐morbidities
 “Relapse”
Relapse = hospitalization, ER visit or detox = hospitalization ER visit or detox
with a primary substance use diagnosis
 Expenditures = average monthly Medicaid expenditures for all care received
expenditures for all care received
 Deaths from Medicaid records
Changes in Opioid Treatment
Changes in Opioid Treatment
 More than 38,000 individuals had an opioid diagnosis between 2003 and 2007
g
 Numbers increased from 14,237 in 2003 to 20 838 in2007
20,838 in2007
 More than 80% of the increase is attributable to buprenorphine treatment
 Only 20% overlap between buprenorphine Only 20% overlap between buprenorphine
users and methadone users.
MassHealth Payments & Relapse Rates
Treatment
Buprenorphine
N = 10,248
Methadone
N = 16 691
N = 16,691
Outpatient drug‐
free (only)
N = 13,768
No treatment
N 1 995
N = 1,995
1
Monthly Expenditures (
(2007 dollars)
d ll )
Regression –
adjusted d ff
differences
Number of relapse events1
Regression –
adjusted 1,220
Reference
46
Reference
1,159
$29 (p<0.07)
28
0.72 (p<0.001)
1,516
$50 (p=0.01)
71
1.25 (p<0.001)
1,087
$149 (p=0.001) 1140
Odds Ratios 2
2.97 (p<0.001)
Per 1000 member months 2 Generalized Estimating Equations adjusting for age, gender, race/ethnicity, CDPS score, mental and physical co‐
morbidities, dual eligibility, number of episodes, and type of health plan
MassHealth Payments & Relapse Rates
Treatment
Buprenorphine
N = 10,248
Methadone
N = 16 691
N = 16,691
Outpatient drug‐
free (only)
N = 13,768
No treatment
N 1 995
N = 1,995
1
Monthly Expenditures (
(2007 dollars)
d ll )
Regression –
adjusted d ff
differences
Number of relapse events1
Regression –
adjusted 1,220
Reference
46
Reference
1,159
$29 (p<0.07)
28
0.72 (p<0.001)
1,516
$50 (p=0.01)
71
1.25 (p<0.001)
1,087
$149 (p=0.001) 1140
Odds Ratios 2
2.97 (p<0.001)
Per 1000 member months 2 Generalized Estimating Equations adjusting for age, gender, race/ethnicity, CDPS score, mental and physical co‐
morbidities, dual eligibility, number of episodes, and type of health plan
6 month mortality
6 month mortality
Treatment
Deaths in ITT period N (%)
Regression –adjusted
Odds Ratios
Buprenorphine
29 (0.28)
Reference
55 (0.33)
0.91
N = 10,248
Methadone
p = 0.65
N = 16,691
Outpatient drug‐free
(only) N = 13,768
83 (0.60)
1.75 No treatment
14 (0.72)
(p=0.01)
2.25
N = 1,995
1
2
(p=0.02)
Per 1000 member months Generalized Estimating Equations adjusting for age, gender, race/ethnicity, CDPS score, mental and G
li d E ti ti E
ti
dj ti f
d
/ th i it CDPS
t l d
physical co‐morbidities, dual eligibility, number of episodes, and type of health plan
Summary of Results
Summary of Results
 Slightly
Slightly lower
lower expenditures for buprenorphine
expenditures for buprenorphine
 More relapse events for drug‐free and no t t
treatment than buprenorphine
t th b
hi
 Fewer relapse
p events for methadone than buprenorphine
 More deaths for drug‐free and no treatment
deaths for drug free and no treatment
Limitations/Remaining questions
Limitations/Remaining questions
 Non Medicaid funded services not included
 Unobserved differences in treatment Unobserved differences in treatment
selection?
 How does treatment affect arrest and H d
ff
d
incarceration and vice versa?
 What role does quality of care play in outcomes and costs?
outcomes and costs?
Conclusions
 Buprenorphine is equally or less expensive than other treatments when total Medicaid expenditures are considered
 Mortality rates suggest that it is comparatively Mortality rates suggest that it is comparatively
safe
 Evidence does not support rationing
Thank you