Medicare Claims for Opioid Use Disorder Medications Spike Post-Coverage Update

Carter H. Nakamoto, BA

Credit: The Farhat Lab, Department of Biomedical Informatics
Harvard Medical School

Since Medicare began covering opioid treatment programs, there has been a significant rise in claims for these services among Medicare beneficiaries with opioid use disorders (OUDs).¹

“These results provide suggestive evidence that the initiation of Medicare coverage of [opioid treatment program] care led to more Medicare beneficiaries receiving [medications for opioid use disorder],” wrote investigators, led by Carter H. Nakamoto, BA, from department of health care policy at Harvard Medical School, in Boston.

Medicare started paying for OUD medications at opioid treatment programs in January 2020.² Yet, little research has been done to see if the payment change led to more patients receiving OUD medications.¹

Investigators conducted a cross-sectional study aiming to describe how many Medicare beneficiaries received care from opioid treatment programs in 2022 and how this compares to people receiving OUD medication from other places in the same year. The sample included all patients receiving an OUD medication in 2019 – 2022 from US Medicare Parts B and D claims. The study included patients who were insured by both Medicare and Medicaid in 2019 – 2020.

Investigators found the number of Medicare beneficiaries treated with opioid treatment programs rose steadily from 4 per 10,000 (14160 beneficiaries) in January 2020 to 7 per 10,000 (25,596 beneficiaries) in August 2020. The number of beneficiaries plateaued through December 2022, with 38,870 patients treated at an opioid treatment program.

In 2022, nearly a quarter of the beneficiaries (23%) were aged ≥ 66 years. Additionally, 35% were female, and 96% received methadone. Investigators found patients in the opioid treatment programs were more likely than those treated in other settings to be ≤ 65 years (65% vs 62; P < .001) and an urban resident (86% vs 74%; P < .001). Conversely, patients in the opioid treatment were less likely to be White (72% vs 82%; P < .001).

The team observed when Medicare started covering opioid treatment programs, there was no associated reduction in the number of people who had dual insurance of Medicare and Medicaid with an opioid treatment program claim. Investigators noted, out of the 1865 opioid treatment programs, 1115 patients (60%) billed Medicare in 2022. However, those with dual insurance billed Medicare anywhere from 13% to 100% across states.

Investigators pointed out 1 caveat: approximately 6% of patients pay cash for opioid treatment programs.

“It is possible that some Medicare beneficiaries were paying cash for their [opioid treatment program] care prior to 2020, then after January 2020 Medicare paid for their [opioid treatment program] care instead,” investigators wrote. To the degree that this is the case, this would not represent an increase in the number of patients receiving MOUD and instead mean that insurance was now paying for the care.”

The team also wrote how, among the Medicare fee-for-service population, most of the rise in OUD medication treatment from 2020 to 2022 came from greater use of OUD medication outside of opioid use treatment. Only a minority of patients receive care from an opioid treatment program. However, in the US there has been a rise in the number of opioid treatment programs in the past 5 years, and Medicare covering opioid treatment programs could potentially be a contributing factor.

“After the start of Medicare’s payment policy, we observed that the total share of beneficiaries receiving [medications for opioid use disorder] …nearly doubled without evidence of a switch in payer from Medicaid to Medicare,” investigators wrote.

References

1. ^{Nakamoto CH, Huskamp HA, Donohue JM, Barnett ML, Gordon AJ, Mehrotra A. Medicare Payment for Opioid Treatment Programs. JAMA Health Forum. 2024;5(7):e241907. doi:10.1001/jamahealthforum.2024.1907}
2. ^{Medicare program; CY 2020 revisions to payment policies under the Physician Fee Schedule and other changes to Part B payment policies; Medicare Shared Savings Program requirements; Medicaid Promoting Interoperability Program requirements for eligible professionals; establishment of an ambulance data collection system; updates to the quality payment program; Medicare enrollment of opioid treatment programs and enhancements to provider enrollment regulations concerning improper prescribing and patient harm; and amendments to physician self-referral law advisory opinion regulations. 84 FR §40482 (2019). Accessed June 17, 2024. https://www.federalregister.gov/documents/2019/08/14/2019-16041/medicare-program-cy-2020-revisions-to-payment-policies-under-the-physician-fee-schedule-and-other}