We know which patient will have a better outcome. We know that the emergency department (ED) is a key touchpoint to engage patients into treatment. We know that patients are at high risk for recurrent overdose and death after ED treatment. And we know that initiation of buprenorphine, with warm handoffs to addiction services, doubles the rate of engagement in treatment at 30 days.
Despite what we know, many hospitals continue to do little more than reverse the overdose for patients that come to the ED. How do we get more hospitals to adopt evidence-based practices?
Some states, like Massachusetts, now mandate that all EDs offer medication treatment and connect patients with substance use treatment. Other states, like California, provide training and resources to hospitals ready to implement new approaches to treatment. Some federal funding (for example, through the Substance Abuse and Mental Health Services Administration) is available for hospitals to develop systems to care for patients with opioid use disorder (OUD).
Pennsylvania chose another path. In 2019, it established the first voluntary financial incentive program to improve ED treatment and follow-up for patients with OUD. The Opioid Hospital Quality Improvement Program (HQIP), developed by the Office of Medical Assistance Programs in collaboration with the Hospital and Healthsystem Association of Pennsylvania, reallocates hospital revenue assessed by the state in the form of quality initiatives.
Hospitals could earn incentive payments by implementing one or more clinical pathways for ED patients with OUD, with increasing incentives for each of these pathways:
A hospital attesting to having one pathway earned a base payment of $25,000; two pathways, $37,000; three pathways, $56,000, and four pathways, $75,000. Hospitals could earn up to $193,000 in 2019 from this process incentive, with additional funds distributed from a total pool of $30 million.
Did this incentive work? We evaluated adoption of clinical pathways among hospitals in Pennsylvania in a recent publication in JAMA Network Open.
The short answer – yes, the incentive worked. Of 155 Pennsylvania hospitals, 80 percent responded by developing at least one of the four pathways. While hospitals did not have to demonstrate effectiveness, the simple existence of the pathways represents a significant – and rapid – change in practice.
Of course, there is a more nuanced answer. We found that only half of hospitals adopted all four pathways. The pathways least likely to be adopted involved the initiation of medication treatment (the most effective way to prevent future overdose). Hospitals unwilling to develop the ability to provide this treatment may be delaying care for patients who need it, when they need it most.
To learn more, we discussed the program with leaders from hospitals around the state. In this second study (under review), we found that hospitals relied on local community partnerships to deploy the pathways. Even before the incentive, many hospitals (led by internal champions) were interested in improving treatment for opioid use disorder. Yet the actual amount of funding was less important than the permission the program gave leaders to prioritize this issue and accelerate change. However, initiation of buprenorphine was seen as a challenge by many organizations, as was the ability to collect accurate data on patients after discharge from the hospital.
The Pennsylvania HQIP offers hospitals a second bite at the apple, with performance incentives for annual improvements in the rate of Medicaid patients receiving follow-up treatment for OUD within seven days after an ED visit. Starting this year (2020), the state will monitor Medicaid claims and allocate $35 million annually in benchmark and incremental improvement incentives.
Pennsylvania’s program represents a novel strategy to encourage hospitals to provide the rapidly advancing standard of care for patients with OUD. While further evaluation of the policy and its impact on treatment is needed, it spurred a process change in a short time. As such, it is another step toward helping all patients receive the best care regardless of which emergency department in which they find themselves.