Costs of Care for Persons with Opioid Dependence In Two Integrated Health Systems Frances Lynch, PhD April 30, 2012 HMO Research Network Conference 2012

1. Costs of Care for Persons with
Opioid Dependence
In Two Integrated Health Systems
Frances Lynch, PhD
April 30, 2012
HMORN Research Conference
Seattle, WA
© 2011, KAISER PERMANENTE CENTER FOR HEALTH RESEARCH

2. Co-Authors
Dennis McCarty, PhD (Principal Investigator)
Jennifer Mertens, PhD
Nancy Perrin, PhD
Carla A. Green, PhD
Sujaya Parasarathy, PhD
Bradley Anderson, MD
David Pating, MD
We gratefully acknowledge funding from the National Institute on Drug Abuse, (R01 DA016341)
© 2011, KAISER PERMANENTE CENTER FOR HEALTH RESEARCH

3. BACKGROUND
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4. Opioid Dependence
 Opioid dependence – inability to stop using opioids (e.g., heroin,
oxycodone) even with significant negative consequences
 Prevalence is difficult to determine accurately
 Common estimate 600,000 opioid addicts & 2 million abusers
 Dependence on prescription pain relievers is growing –
 20% increase between 2004 and 2009 (NSUDH 2009)
 Youth, older adults, and women, may be at particular risk
 Opioid abuse and dependence has high costs to individuals,
health care systems, and society
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5. Opioid Dependence in private health
systems
 In past, private health care systems have been reluctant to treat
opioid dependence
 Concerns about attracting high risk populations
 Treatments difficult to administer well
 Changes in patterns opioid use and health insurance are
changing private systems interest in treating opioid dependence
 Issues for private health systems include:
 Costs of providing opioid dependence treatment
 Costs of managing affects of opioid use on member’s health
 Avoiding misuse of opioid drugs
 Maintaining appropriate management of chronic pain
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6. Treatment of Opioid Dependence
 Methadone
 Addiction Medicine Counseling
 Group
 Individual
 Buprenorphine
 Other Medications
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7. Buprenorphine
 Drug Abuse Treatment Act of 2000
 Authorized waivers for qualified physicians
 Caseload = 30 or less patients per group (i.e., a health
plan)
 FDA approved October 2002
 DATA 2000 amended: caseload =30 or less
patients per physician (December 2005)
 DATA 2000 amended: caseload =100 or less
patients per physician (January 2007)
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8. Motivation for studying opioid dependence in
private health systems
 Most health plans have little experience with opioid
agonist treatment
 Growing interest in agonist therapy
 Growing private health system population with opioid dx
 Effectiveness and ease of use of buprenorphine
 Some research suggests buprenorphine is more costly
than methadone
 Health systems need information about relative costs of
treatment options in real world health care settings
© 2011, KAISER PERMANENTE CENTER FOR HEALTH RESEARCH

9. Study Objectives:
 Describe health care and addiction medicine services
for persons with opioid dependence in two integrated
health systems
 Examine health system costs for persons with opioid
dependence and assess the impact of buprenorphine
on those costs
© 2011, KAISER PERMANENTE CENTER FOR HEALTH RESEARCH

10. DESCRIPTION OF STUDY:
Adoption of Buprenorphine in Two
Private Not-for-Profit Integrated Health Systems
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11. Methods: Study Design
 Retrospective cohort with data from 2 not-for-profit health systems
 Included all persons with
 2 or more diagnoses of opioid dependence in a given year
 Between 2000 and 2008
 Classified patients into four groups:
 methadone plus counseling,
 buprenorphine (but no methadone) plus counseling,
 two or more counseling sessions (and no medication)
 one or fewer counseling sessions (and no medication)
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12. Statistical Analyses
 Descriptive analysis of trends over time in opioid dx
and treatment modalities
 GEE models to examine pattern of total health plan
costs and types of service use over time by
treatment group
 Used propensity scores to help control for
differences in patient characteristics related to
treatment group
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13. Figure 1. Trends Over Time in Opioid Diagnoses and Treatments
Health Plan A
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14. RESULTS
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15. Figure 2. Trends Over Time in Opioid Diagnoses and Treatment
Health Plan B
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16. Table 1: Description of Sample
Health System A Health System B
N= 4425 N=7122
Age (mean, sd) 41(14) 43 (13)
Gender (% female) 50% 53%
N for Implementation Period
Little or no AM 30 pt/MD =379 30 pt/MD =977
counseling 100 pt/MD =531 100 pt/MD =1301
AM Counseling Only 30 pt/MD =389 30 pt/MD =1722
100 pt/MD =508 100 pt/MD =1781
Buprenorphine plus 30 pt/MD =379 30 pt/MD =219
AM counseling 100 pt/MD =835 100 pt/MD =1122
Methadone plus AM 30 pt/MD =692 N/A
counseling 100 pt/MD=797

17. Table 2: Adjusted Mean Annual Cost by Time Period (2008 $)
Implementation
Health System A Health System B
Period
16,894 15,434
30 pt/MD
AM Counseling (14,399-19390) (14,180-18,610)
Only 18,617 17,445
100 pt/MD
(15,401-21,833) (16,280-18,610)
26,046 21183
30 pt/MD
Little or no AM (21,252-30,840) (18662-23703)
counseling 26,292 22041
100 pt/MD
(22,522-30,062) (19374-24707)
16,230 17240
Buprenorphine 30 pt/MD
(14,352-18,107) (15326-19515)
Plus AM
Counseling 17,921 18150
100 pt/MD
(16,131-19,711) (16589-19711)
10,789
30 pt/MD
Methadone Plus (7310-14,267)
N/A
AM Counseling 12,379
100 pt/MD
(10,201-14,558)

18. Table 3: Health Care Service Use Means (SD) Health System A
Implementation Inpatient AM PC ER MH Other
Period Detox Residential visits visits visits visits
Stays
AM Counseling .18 .18 5.10 1.12 3.17 4.24
30 pt/MD
Only (.14) (.14) (.06) (.14) (.16) (.08)
0.17 .15 5.11 0.95 3.46 3.82
100 pt/MD
(.14) (.16) (.05) (.12) (.14) (.08)
Little or no AM .03 .01 4.90 1.40 2.25 4.37
30 pt/MD
counseling (.35) (.59) (.06) (.14) (.18) (.11)
.01 .01 5.09 0.92 3.64 4.74
100 pt/MD
(.44) (.61) (.06) (.14) (.21) (.12)
Buprenorphine .46 .13 4.06 0.88 1.67 3.09
30 pt/MD
Plus AM (.09) (.15) (.05) (.13) (.19) (.09)
Counseling
.27 .11 3.86 0.66 2.03 3.02
100 pt/MD
(.10) (.15) (.06) (.13) (.15) (.08)
Methadone Plus .02 .01 3.30 0.66 0.82 2.415
30 pt/MD
AM counseling (.29) (.37) (.06) (.14) (.18) (.10)
.03 .02 3.59 0.50 1.04 2.94
100 pt/MD
(.33) (.33) (.06) (.14) (.16) (.09)

19. Table 3: Health Care Service Use Means (SD) Health System B
Implementation Inpatient AM PC ER MH Other
Period Detox Residential visits visits visits visits
Stays
AM Counseling Only .02 .05 5.60 1.47 3.06 8.09
30 pt/MD (.19) (.13) (.03) (.06) (.08) (.04)
0.03 .05 5.87 1.59 3.59 7.25
100 pt/MD (.15) (.13) (.02) (.05) (.09) (.04)
Little or no AM .01 .00 7.10 1.69 2.97 6.74
counseling 30 pt/MD (.43) (.61) (.03) (.06) (.10) (.05)
.01 .01 6.57 1.76 3.31 7.12
100 pt/MD (.44) (.44) (.03) (.06) (.12) (.05)
Buprenorphine Plus AM .05 .10 4.82 1.44 1.89 10.15
Counseling 30 pt/MD (.31) (.23) (.07) (.13) (.17) (.14)
.03 .06 5.41 1.39 2.85 6.71
100 pt/MD (.28) (.16) (.03) (.08) (.11) (.05)

20. Limitations
 Retrospective cohort design, no randomization to
treatment
 Treatment group selection likely.
 No detailed information on drug use history
 Study in Western United States, may not generalize to
other areas
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21. Summary and discussion
 Buprenorphine successfully provided for persons with
opioid dependence in two integrated health systems
 Buprenrorphine patients had higher total costs compared
to methadone patients
 Buprenorphine patients had similar total costs to patients
receiving counseling
 Buprenorphine patients had lower total costs compared to
patients with little or no treatment
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22. Importance of health system infrastructure to
support buprenorphine-assisted treatment
 Health plan A implemented more quickly
 Smaller system – only to two sites offering Buprenorphine,
with one chief of both
 Staff had prior experience using buprenorphine from a
clinical trial
 Health plan B implemented more slowly
 Substantially larger system - over 20 clinics treating opioid
dependence
 Each clinic had separate chief and each clinic developed
its own procedures
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23. Preliminary Conclusions
 Buprenorphine can be successfully offered in
integrated health systems to privately insured patients
 Total health system costs of buprenorphine are
similar to total costs for patients in abstinence-based
counseling
© 2011, KAISER PERMANENTE CENTER FOR HEALTH RESEARCH