Pregnancy and insurance status were significant barriers to obtaining appointments for opioid use disorder treatment. These findings, from a cross-sectional study in the United States, were published in JAMA Network Open.
This study was designed in a ‘secret shopper’ format, where simulated-patient callers were randomly assigned to outpatient clinics that provided methadone and buprenorphine in 10 states. Clinics were selected from publicly available treatment lists and were contacted between March and September of 2019.
In total, 28,651 calls were made by 10,871 callers to 6324 clinicians (5944 buprenorphine-waived prescribers). The callers posed as Black, White, or Hispanic women who were aged 25 to 30 years, who were pregnant or not pregnant. Both public and private clinics were contacted for an initial appointment with a buprenorphine-waiver prescriber or an opioid treatment program (OTP).
The success rate was higher for reaching an OTP (71.1%) than for buprenorphine prescribers (33.8%). The most common contact failure was defined as 5 unanswered calls (buprenorphine 23.8% vs OTP 8.2%). The median number of calls to reach a staff member who could schedule an appointment was 2 for both types of clinics (interquartile range [IQR], buprenorphine: 1-5 calls vs OTP: 1-3 calls).
Pregnant women were significantly less likely to obtain an appointment with a buprenorphine prescriber (61.4% vs 73.9%; relative risk [RR], 0.83; 95% CI, 0.79-0.87) compared with nonpregnant women. Success rates for women varied by state. Pregnant women were least successful at obtaining an appointment with a buprenorphine prescriber in Kentucky (48.1%) and most successful in North Carolina (70.4%; P <.001). Nonpregnant women were least successful in Michigan (61.2%) and most successful in Florida (83.0%; P <.001).
The investigators did not observe a significant difference between pregnant and nonpregnant women obtaining appointments with an OTP (88.6% vs 89.4%; RR, 0.99; 95% CI, 0.93-1.05), respectively. However, pregnant women were offered an appointment sooner than nonpregnant women (median, 1 day vs 2 days; P =.049).
Women insured with Medicaid were less successful at scheduling an appointment with a buprenorphine prescriber compared with private insurance (40.3% vs 49.2%; P <.001). Insurance acceptance varied significantly by state. Medicare was accepted at only 16.6% of buprenorphine-waiver prescribers in Florida compared with 57.0% of clinics in Massachusetts (P <.001); and for OTPs, Medicare was accepted least in Tennessee (7.7%) and most in Massachusetts (88.0%; P <.001).
At buprenorphine-waiver prescribers and OTPs, women were only given an appointment when they agreed to pay in cash at 26.1% and 32.5% of contacted centers, respectively. The median cost for the initial appointment was $250 (IQR, $155-$300) at a buprenorphine prescriber clinic and $34 (IQR, $15-$120) at an OTP.
A limitation of this study was that clinics in only 10 states were contacted, and as rates of success and insurance acceptance varied significantly, these data may not be generalizable across the entire United States.
The study authors concluded there was a significant burden for accessing care for opioid use disorder, and that women who were pregnant or had Medicaid had more difficulty when setting up evaluation with a buprenorphine-waiver prescriber.
Patrick S W, Richards M R, Dupont W D, et al. Association of pregnancy and insurance status with treatment access for opioid use disorder. JAMA Netw Open. 2020;3(8):e2013456. doi:10.1001/jamanetworkopen.2020.13456