Telehealth Improves Access to Treatment for Substance Use Disorder
Published Jan. 22, 2021
- About 400,000 Tennesseans have substance use disorder (SUD). The rate of fatal opioid overdose has more than quadrupled since 1999, killing 1,307 Tennesseans in 2018. Though this rate is starting to decline for the U.S. overall, the rate continues to rise in this state. 82% of fatal prescription opioid overdoses and 92% of fatal heroin overdoses have been determined to be accidental, meaning the vast majority of these deaths are preventable with evidence-based treatment.
- Access to care is severely limited, however. Only 1 in 10 Tennesseans who need treatment for SUD obtain it. This is mainly due to local provider shortages, long distances between a small number of treatment centers, stigma, and cost. Rural areas are especially impacted. In 2017, over a third of Tennessee counties had zero providers who could prescribe buprenorphine, the most common of the Medications to treat Opioid Use Disorder (MOUD).
- Telehealth directly addresses all of these barriers and improves access to care. During the COVID-19 pandemic, usage significantly increased when the state expanded telehealth permissions. Patients, providers, and major insurers have responded favorably.
- It is estimated that SUD involving opioids costs Tennessee $183.1 million per year in lost workplace productivity and healthcare costs, but every $1 spent on evidence-based treatment for SUD saves $12 in healthcare and criminal justice costs. In order to improve access to treatment for SUD in the long term, these pandemic-era telehealth permissions should be made permanent.
Barriers to Access
Only 1 in 10 Tennesseans who need SUD treatment receive it. This is largely due to “very limited treatment availability in several locations.” For many Tennessee counties, the number of SUD treatment resources is not proportional to the number of overdose deaths, and in fact, many rural areas have zero providers that can prescribe medications to treat opioid use disorder (MOUD) such as buprenorphine. In other words, the areas most in need of MOUD programs have the fewest.
More than 1 in 4 patients travel at least 15 miles to their MOUD clinic, and almost 10% travel an average of 50 miles to another state. This reduces income and productivity, especially in rural areas.
The treatment itself is expensive. “Although costs of [MOUD] vary considerably across and within states, out-of-pocket payments are approximately $42 to $166 per week for methadone and considerably higher for buprenorphine.” Low income and disabled patients are more likely to drop out of MOUD programs because of the cost related to traveling to and keeping their appointments. Some patients have even taken to selling some of their doses on the street so they can pay for their prescriptions.
Stigma is another barrier to access. Stigma can cause shame and embarrassment for patients presenting for MOUD, or when arranging time off from work to meet their appointments. Stigma can also encourage constituents to fight against the opening of new MOUD programs, even if their communities are in need.
Telehealth Improves Access
Telehealth directly addresses all of these barriers. Patients in areas without local MOUD programs are able to access them anywhere in the state. This also reduces the impact of stigma, as patients are able to obtain treatment in the comfort of their own homes. Telehealth also reduces total healthcare costs while improving medication adherence. Furthermore, telehealth has been associated with better healthcare outcomes overall and high patient satisfaction.
In response to the COVID-19 pandemic, Governor Bill Lee issued Executive Order #15 in mid-March, 2020. This mandated reimbursement parity for all telehealth services at a rate equal to their in-person equivalents. In the one-month period of March-April, BlueCross BlueShield reported an 18-fold increase in telehealth claims, and announced it would make telehealth a permanent feature of its in-patient networks. In August, 2020, Public Chapter 4 of the 111th General Assembly Second Extraordinary Session passed, expanding telehealth permissions and reimbursement parity further (HB8002/SB8003). This public chapter allows patients to access telehealth wherever they are physically located, and permits SUD service providers to use telehealth to satisfy the patient-provider relationship and begin online prescribing – a necessary component of evidence-based treatment for SUD. However, this law is set to repeal on April 1st, 2022.
Telehealth improves access to care by eliminating physical distance as a barrier, addresses the rural provider shortage, reduces costs, improves healthcare outcomes and is associated with high patient satisfaction. Telehealth has already been made a permanent feature of BlueCross BlueShield’s in-network plans. The expansion of telehealth permissions in response to COVID-19 have led to a significant increase in access to treatment, especially as it pertains to SUD. The state should examine the benefits of the legislation and consider making the law permanent before it expires in April, 2022.
Expert Opinion: Stephen Loyd, MD
Telehealth has “let the genie out of the bottle,” says Dr. Stephen Loyd, Chief Medical Officer of Cedar Recovery. “It’s given us access to our patients’ lives.”
He spoke with PBS NewsHour last September and with the SMART Policy Network in November, advocating for the continuation of changes to telehealth regulation brought about by special session legislation in response to the COVID-19 pandemic. He says the expansion of telehealth permissions have significantly improved access to care for his Middle Tennessee patients seeking treatment for SUD.
When patients with SUD are “finally ready” to receive treatment, they are often in situations that make accessing care extremely difficult. They might be involved in the criminal justice system, they might not have a driver’s license; they can face community stigma for simply showing up at the clinic. “Telehealth erased these barriers.”
“It shouldn’t replace in-person appointments completely,” he says, “but the audio-visual technology is sufficient going forward, and medication-assisted therapy should be able to start with telehealth.” Though a provider cannot put a stethoscope to a patient’s chest, “you can see track marks, pupil size, and other signs of abuse or withdrawal on these high-def cameras.” In other words, it is sufficient to begin treatment.
Telehealth also permits unprecedented insight into patients’ personal lives. “You see into their homes, their cars, hotel rooms or tents underneath the interstate.” For Dr. Loyd, who emphasizes a compassionate approach to rehabilitation, telehealth offers an opportunity to not only expand access to care, but to improve the quality of care because of this insight. “That first interaction is my favorite,” he says. “You get to see them raw… see them feel things for the first time in a long while.”
Policy Brief Authors:
Jeremy Kourvelas, UTK MPH student
Carole Myers, PhD, Professor, UTK College of Nursing
Katie Cahill, PhD, Associate Director, UTK Howard H. Baker Jr. Center for Public Policy
Stephen Loyd, MD, Cedar Recovery & New Hope Treatment Center
Jennifer Tourville, DNP, UT Director of Substance Misuse Outreach and Initiatives
The SMART Policy Network Steering Committee Members