Emergency Department Treatment-Linkage Financial Incentive Policies

Research Brief

Provide monetary performance incentives to hospitals that can attest to the following for patients with a diagnosis of opioid use disorder (OUD) admitted to an emergency department (ED) (but not to inpatient treatment): (1) initiated buprenorphine treatment during the ED encounter and (2) provided a warm handoff to outpatient treatment. .

A panel of experts rated how they expect this type of policy to affect four outcomes: OUD treatment engagement, OUD treatment retention, OUD remission, and opioid overdose mortality. Another panel of experts rated the policy on four decisionmaking criteria: acceptability to the public, feasibility of implementation, affordability from a societal perspective, and equitability in health effects.

Policy Recommendations According to Expert Ratings

Oppose Uncertain Support
No
No
Yes

Summary of Expert Ratings

Outcomes Effect Rating
Harmful Little-to-no Beneficial
OUD Treatment Engagement
No
No
Yes
OUD Treatment Retention
No
Yes
No
OUD Remission
No
Yes
No
Opioid Overdose Mortality
No
No
Yes
Criteria Implementation Rating
Low Moderate High
Acceptability
No
No
Yes
Feasibility
No
Yes
No
Affordability
No
No
Yes
Equitability
No
No
Yes

Summary of Expert Comments

  • Experts expect the policy to have meaningful positive impacts on OUD treatment engagement and opioid overdose mortality.
  • Experts believe that the public increasingly supports policies that facilitate linkages to medication for opioid use disorder (MOUD) and evidence-based treatment for OUD.
  • While experts emphasized that the equitability of all policies depends on how they are implemented, they found this particular policy inherently equitable because it explicitly would address a setting serving patients with disparate health outcomes related to opioid use.
  • Experts believe the policy could be cost-saving (in the long run) and could minimize costs given other trends in health care.
  • The policy is feasible, although its feasibility may vary across states and health care systems depending on buy-in, logistics, administrative burdens, treatment capacity, and resources for financial incentives.

Outcome Summaries

OUD Treatment Engagement

Percentage of people meeting the criteria for an OUD diagnosis who receive two or more OUD treatment services (including medication for OUD) within 34 days of initiating treatment.

Effect Rating Summary of Expert Opinion Representative Quotations
Beneficial

(selected)
Financial incentives, MOUD initiation, and warm handoffs facilitate treatment integration that would increase initial contacts with substance use disorder (SUD) services among those not currently receiving OUD treatment. ED encounters for individuals with OUD not currently engaged in care are common. ED initiation of [buprenorphine] clearly demonstrated to be feasible”
Little-to-no Depends on the outpatient treatment (availability, program champions, quality), design of the incentives (amount, who receives them), and how quickly the warm handoff occurs. “This really depends on the financial incentives and what level it goes to. If to the department or program, then maybe it will be more likely to have an impact on engagement. Will depend on availability of treatment slots in the community. Engagement will depend largely on the treatment partners”
Harmful N/A N/A

OUD Treatment Retention

Percentage of people meeting the criteria for an OUD diagnosis who remain continuously enrolled in OUD treatment services for at least six months.

Effect Rating Summary of Expert Opinion Representative Quotations
Beneficial Greater access to MOUD and outpatient services should increase retention. “More people getting referred from the ED to [medication-assisted treatment] programs rather than ‘drug-free’ programs should improve retention in those folks”
Little-to-no

(selected)
Policies focus more on engagement than on retention. Long-term retention would depend on financial incentives, ED treatment availability, follow-ups with patient, and social supports. “The ED incentives will be less likely to have lasting impact on retention and that may depend on other factors such as availability and social supports”
Harmful N/A N/A

OUD Remission

Percentage of people meeting the criteria for an OUD diagnosis who do not experience OUD symptoms (other than craving/desire/urge for opioid) for at least 12 months.

Effect Rating Summary of Expert Opinion Representative Quotations
Beneficial Facilitating initiation of (long-term) treatment can improve remission. “Could be a useful way to get people into long-term treatment because sometimes all they need is that initial motivation to do so. A trip to the ED plus MOUD plus a warm handoff to treatment is a great combination”
Little-to-no

(selected)
Policies focus on initial engagement with less attention to other factors needed for sustained remission. Also would depend on warm handoff, sustained funding for financial incentives, and continued follow-up with patients. “If treatment engagement increases … then downstream effects on the OUD cascade of care and outcomes would be expected. However, there are a lot of other factors that affect remission (e.g., individual barriers as well as the treatment context), so the magnitude on this outcome would likely be smaller”
Harmful N/A N/A

Opioid Overdose Mortality

Per capita rates of fatal overdose related to opioids, including opioid analgesics (e.g., oxycodone), illegal opioids (e.g., heroin), and synthetic opioids (e.g., fentanyl).

Effect Rating Summary of Expert Opinion Representative Quotations
Beneficial

(selected)
Directly reduces probability of overdose in a high-risk period and population via MOUD and treatment linkages. “Good ED policies are critical to overdose mortality since people are coming in a moment of crisis”
Little-to-no Depends on how the policies would be combined with harm reduction measures (e.g., opioid overdose education and naloxone distribution programs) and sustained patient use of MOUD. Population-level mortality is a result of more factors than those targeted by these policies. “If treatment in the ED included harm reduction, naloxone dispensing, etc., then this could lead to a large decrease in overdose mortality”
Harmful N/A N/A

Implementation Criteria Summaries

Acceptability

The extent to which the policy is acceptable to the general public in the state or community where the policy has been enacted.

Implementation Rating Summary of Expert Opinion Representative Quotations
High

(selected)
Increases support for MOUD and linkages to evidence-based treatment given widespread publicity to overdose epidemic (though stigma still an issue). “Robust responses to any health emergency, including OUD/SUD, traditionally has broad support by the general public”
Moderate Potential concerns about MOUD diversion, providing incentives to hospitals (to “do their job”), and perceptions of policy as a pharmaceutical industry initiative. “In the general public there is the risk of this kind of policy being perceived as the hospital being paid for starting medications and concern that somehow [pharmaceutical companies are] behind it”
Low N/A N/A

Feasibility

The extent to which it is feasible for a state or community to implement the policy as intended.

Implementation Rating Summary of Expert Opinion Representative Quotations
High Similar to existing mechanisms for bridge programs and pay-for-performance models. “Lots of states have these bridge programs already, and there is research that supports it”
Moderate

(selected)
Depends on ED and provider buy-in, logistical complexity of coordinating linkages, administrative burden of attestations, ED and outpatient treatment capacity, and funding for and logistics of financial incentives. Will vary across states and health care systems. “Significant investments would be needed to connect, coordinate, and incentivize high-quality ED to outpatient care transitions, given the complexities of system design and financing. … Right now, it is challenging for outpatient providers to even know when patients are seen in the ED, let alone get them connected to specialty care or back into their [provider’s] office following those events”
Low Barriers include variable geographical access to EDs and ED staff knowledge about these practices. “Geographical gaps in treatment likely to be a barrier to the ED having the ability to do this”

Affordability

The extent to which the resources (costs) required to implement the policy are affordable from a societal perspective.

Implementation Rating Summary of Expert Opinion Representative Quotations
High

(selected)
Cost-saving and most changes in practices could have minimal costs given other trends in health care (expansion of allied health professionals, electronic medical records, MOUD) “This is an affordable approach if there is hospital ED buy-in, and there are ‘peer specialists’ or ‘community health worker’ supports available in the ED setting and for follow-through”
Moderate Cost-effective in the long run, but substantial initial and continuing expenses (hiring staff to coordinate warm handoffs, prescribers of MOUD, and financial incentives). “It probably will involve increased costs and resources, but it will be cost-effective in the long run”
Low Requires significant resources and effects are small compared with the resources required. “There is a lot of money going into this and outcomes are not that impressive largely because it requires a lot of implementation support at individual hospitals and more willing linkages with outpatient settings. Creating systems that connect inpatient and outpatient providers have always been very, very challenging”

Equitability

The extent to which the policy is equitable in its impact on health outcomes across populations of people who use opioids.

Implementation Rating Summary of Expert Opinion Representative Quotations
High

(selected)
Policy inherently increases linkages to evidence-based treatment for a patient population and setting with disparate health outcomes related to opioid use. EDs may reach more marginalized populations than other health settings”
Moderate Depends on implementation of incentives, particularly in low-resource settings and small or rural areas. Also influenced by bias of staff implementing warm handoffs. “Lesser resourced hospitals (rural and urban underserved, non-academic settings) often have a harder time implementing new programs, even when incentives are available. However, there may be ways to address this if public systems offered free training and technical assistance to help them get up to speed more quickly”
Low Inequitable without including methadone treatment in these policies. “Methadone induction in a hospital setting should be possible or we will lose all those buprenorphine intolerant people”

Research conducted by

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