Financial Incentives Increase X-Waiver Training, Buprenorphine Prescription Rates

doctor writing prescription
doctor writing prescription
Financial incentives improved X-waiver training completion and buprenorphine prescribing rates in emergency department physicians.

Financial incentives improve completion rates of X-waiver training and buprenorphine prescription rates by emergency department (ED) physicians for opioid use disorder, according to a study published in the Annals of Emergency Medicine.

Researchers conducted a prospective, observational cohort to evaluate the influence of a financial incentive program on physician behavior for obtaining an X waiver for buprenorphine prescription. The financial incentive period was held for 6 weeks from mid-November through the end of 2018. From January to May 2019, the researchers analyzed and compared the effect of X-waiver training with the 8-month period prior to the financial incentive period, April to November 2018.

Set in 3 academic EDs within a single health care system in Philadelphia, Pennsylvania, the study sites were affiliated with the same residency and only 1 site had a trauma designation. Across the 3 sites approximately 6% (4 of 67) faculty members had X-waiver training and buprenorphine prescription was found to be uncommon. All active, full-time, attending ED physicians across all sites were included in the study and patient encounters were selected based on presence of an opioid use disorder-related International Classification of Diseases, 10th Revision code.

In November 2018, 63 attending ED physicians across the sites were offered a $750 incentive as well as a $199 reimbursement for the 8-hour American Society of Addiction Medicine online course to complete waiver training and apply for certification before the December 31, 2018 deadline. Faculty who had previously completed training and certification were ineligible to receive the financial incentive.

Participation was tracked manually by physician self-report that was verified by obtaining X-waiver training certificates. Opioid use disorder-related encounters data was taken from electronic health records and buprenorphine prescription and prescriber data were gathered from an institutional database that accessed data from the electronic health record system used at all 3 sites. An online cross-sectional survey was also conducted 4 months after the financial incentive period to study physician responses to the program in which respondents also received a $5 incentive for survey completion.

The study results showed that 89% (56/63) of the eligible ED physicians completed the waiver training and program participation rates varied from 77% to 100% across the sites. In the 8 months before the financial incentive program, only 2 buprenorphine prescriptions were written for the 396 of opioid use disorder-related encounters (0.51% prescription rate) that occurred across the sites. “After the intervention, the proportion of buprenorphine prescriptions among opioid use disorder-related encounters increased at all sites, although with marked variability in both the prescription rate and magnitude of change across sites,” the study authors wrote.

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In the 5-month postintervention period, 20 physicians (33.3%) wrote ≥1prescriptions for buprenorphine, 34 patients (94.4%) received a single prescription and the remaining 2 patients (5.6%) received 2 prescriptions each. All buprenorphine prescriptions written had quantities sufficient for ≤3 days. The online survey had a response rate of 68.6% (46 of 67) and 73.9% (34 of 46) noted that they had completed training during the study period.

Of the respondents who completed training during the period, 31 of 34, (91.2%) felt prepared to administer buprenorphine afterward and 22 of 34 (64.7%) reported that they administered buprenorphine, provided a prescription for buprenorphine at discharge or did both since completing X-waiver training.

“Our results suggest that a financial incentive, even at a rate below that of clinical care, is effective in prompting physicians to complete X-waiver training,” the researchers concluded.


Foster SD, Lee K, Edwards C, et al. Providing incentive for emergency physician x-waiver training: an evaluation of program success and postintervention buprenorphine prescribing [published online May 3, 2020]. Ann Emerg Med. doi:10.1016/j.annemergmed.2020.02.020