Telemedicine-Based Collaborative Care Policies

Research Brief

Direct state and/or federal funding to implement collaborative care models for the treatment of opioid use disorder (OUD) in which an off-site team of specialty trained addiction clinicians collaborates with on-site primary care providers and their patients, from a centralized location, using telephones, interactive video, and electronic health records.

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 OUD 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
No
Yes
OUD Remission
No
Yes
No
Opioid Overdose Mortality
No
Yes
No
Criteria Implementation Rating
Low Moderate High
Acceptability
No
No
Yes
Feasibility
No
No
Yes
Affordability
No
No
Yes
Equitability
No
Yes
No

Summary of Expert Comments

  • Experts expect better, continuous access to addiction specialists through telehealth to increase OUD treatment engagement and retention, particularly in areas with limited specialist availability and time or transportation barriers to treatment; they do not expect these improvements to affect OUD remission and overdose mortality.
  • Experts think the public generally supports increased access to medical specialists and the greater flexibility offered by telehealth (especially since the coronavirus disease 2019 [COVID-19] pandemic).
  • Experts view the shift to telehealth during COVID-19 mitigation measures (e.g., lockdown) as demonstrating the feasibility and affordability of this policy approach.
  • Experts believe the equitability of these policies depends on a state’s digital infrastructure and internet access and on implementation with an explicit equity lens to address the digital divide across social gradients.

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)
Facilitated access to addiction specialists should increase engagement with treatment, particularly in areas with limited specialist availability and time or transportation barriers to addiction treatment (e.g., rural areas). “I think this would bring expertise to areas that are lacking in providers, i.e., rural areas”
Little-to-no Policies focus on one component of collaborative care that is not the most crucial component and not always taken up in real-world implementation (e.g., due to limited broadband access). “This isn’t collaborative care [CC], it is just one piece of collaborative care, the expert consultation piece. I think that piece is the least important piece of CC. However, if it is part of a larger CC program (where there is a case manager and a registry and measurement based care) then it could be more effective”
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

(selected)
Facilitates continued access to addiction specialists for both patients (i.e., continuity of high-quality care) and providers (i.e., continuity of high-quality support), particularly in areas with limited specialist availability and time or transportation barriers to addiction treatment (e.g., rural areas). “Implementing [these policies] should increase retention as primary care providers would be able to seek guidance/assistance with challenging patients who are at higher risk for treatment dropout. It also should positively impact the professional development over time of primary care providers to improve their skills in treating OUD patients”
Little-to-no Impact will vary by implementation and by context. “Not totally sold. You are suggesting provider to provider telemedicine support? Impact will vary regionally. This only overcomes one of many important provider barriers, and I’m not sure it is the most important one”
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 Improved treatment retention will translate into increases in OUD remission, especially if access to specialists improves primary care providers’ knowledge and skills in addiction medicine. “I think the dose of direct intervention needed to improve remission rates would be more than is realistic. Over time, though, if primary care [doctors] can gain skill in treating addicted individuals, this may improve. Rates can also improve if the collaboration leads to more referrals to specialty care”
Little-to-no

(selected)
Issues with access to and quality of telehealth might prevent improvements in engagement/retention from translating into detectable improvements in population-level OUD remission. “May increase retention by creating [a] lower [to] barrier treatment access but still not everyone can access telehealth”
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 Improved treatment retention will translate into decreases in overdose mortality, especially if access to specialists improves primary care providers’ knowledge and skills in addiction medicine. “Fatal overdoses go down as OUD treatment is more accessible”
Little-to-no

(selected)
Benefits of policy on mortality would be limited by the proportion of people who overdose but do not engage with the health care system. “It is unlikely that this policy will affect per capita overdose mortality. But it will affect overdose mortality for some given the likely improved care because of access to a specialist and presumed higher quality care through a primary care provider”
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)
Public supports increasing access to medical specialists and greater flexibility offered by telehealth (especially since the onset of the COVID-19 pandemic). “I think coordination of care and telehealth are concepts that are generally supported”
Moderate N/A N/A
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

(selected)
Shift to telehealth during COVID-19 mitigation measures (e.g., lockdown) have demonstrated the feasibility of this policy approach. “The infrastructure largely exists in many areas particularly after [COVID-19] telehealth implementation”
Moderate Concerns about difficulty to implement due to complex provider relationships, provider availability, and billing arrangements. “This starts to get very tricky. Provider-to-provider consultation is very difficult in Medicaid. The relationships and care model would have to be delineated very clearly as well as who bills for what. It’s possible that not everyone will get to bill for what they want, which could mean complex contracting relationships between providers”
Low Primary care providers may not have the capacity to incorporate telehealth consults into their overburdened workloads. “[Primary care providers] are enormously busy and there are patient flow issues in coordinating real-time between providers. [Providers do not have] excess capacity in their schedules currently to handle new issues at the scale of our national need and they are unlikely to be paid for the care”

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)
Reduces certain costs in the short run (e.g., transportation, onsite staff) and should be cost-effective in the long run given extended reach of evidence-based care through telehealth. “Affordable policy because it can be built into [Medicaid managed care organization] rates and should yield savings through expanded access to treatment and stabilized [per member per month costs]”
Moderate Potentially resource-intensive (e.g., provider time, technology, administrative burdens). “It’s hard to know without an exact care model but it is likely to be resource-intensive both in terms of provider payments and administrative time to set it up”
Low N/A N/A

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 Telehealth targets disparities in access to health care. “May facilitate equity as it addresses common transportation, childcare, and employment barriers that impede access to appointments”
Moderate

(selected)
Depends on existent digital infrastructure and internet access (i.e., the digital divide). “While telemedicine has the ability to extend or expand access for certain patients, for others, it could further exacerbate disparities due to the digital divide. States should consider allocating funds to allow for supplying of technology to eliminate this digital divide”
Low Potential to be inequitable without an implementation plan that explicitly addresses existing inequitable systems and structures. “I agree with the first comment, from what I can see in our area, telehealth is going to stay and there is a significant risk in not implementing an equity lens to these policies. That would be intentionally building in policies and capacity to ensure that the technology is accessible to everyone; i.e., providing technology to patients, potentially creating spaces in communities where people who are homeless or otherwise do not have privacy can have confidential appointments”

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