May 27, 2020
Lori Uscher-Pines, PhD1; Haiden A. Huskamp, PhD2; Ateev Mehrotra, MD2
JAMA. Published online May 27, 2020. doi:10.1001/jama.2020.3940
Approximately 50,000 deaths from opioid overdose occur each year in the US,1 and the prevalence of heroin use is increasing.2 Although more than 2 million people with an opioid use disorder (OUD) need treatment and an increasing number of individuals are receiving treatment, less than 20% receive effective medications such as buprenorphine.3,4 Individuals may encounter many barriers to receiving medication treatment including inadequate supply and distribution of clinicians who can provide it, stigma related to drug use, and intensity of traditional OUD treatment.5 This approach has become even more important in the midst of the worldwide coronavirus 2019 (COVID-19) pandemic. Telehealth for OUD in the home is a new treatment model that has emerged in recent years that may help to address these issues. In this Viewpoint, we discuss what is contributing to the emergence of this new service, the structure of the care, and how recent federal legislation and COVID-19 may accelerate growth.
In the past, patients with OUD could only receive outpatient medication treatment in various physical locations including office-based physician practices, Federally Qualified Health Centers, and certified opioid treatment programs. However, given that 56% of rural communities do not have clinicians with waivers to prescribe buprenorphine,6 many patients seeking OUD treatment might not have access to care.
Even if a clinician is available, care for OUD requires numerous visits for initial assessment, medication induction, ongoing monitoring, urine drug screening, and delivery of support services (eg, counseling, group therapy). Patients receiving medication treatment also may have to take time off from work and arrange childcare and transportation for their appointments. One study, reported in 2014, found that 52 patients treated in a rural community spent about 5 hours and $50 on transportation-related expenses each week.7 Many patients also may feel embarrassment when seeking treatment in their community given the stigma associated with OUD.
A new treatment model for OUD has emerged in the last few years that leverages telehealth to provide medication treatment to patients in their homes. Any internet search for medication-assisted treatment likely results in advertisements for telehealth companies such as Bicycle Health, Bright Heart Health, PursueCare, and Workit Health that offer medication treatment for OUD. These organizations, as well as multiple competitors, advertise the convenience of their model for OUD treatment. By minimizing the need to travel and increasing privacy for patients who may not want to be seen seeking care, these programs also could address the access challenges that are especially problematic for underserved patients.
Although these organizations prescribe controlled medications to patients in their homes via Health Insurance Portability and Accountability Act–compliant mobile phone applications,8 they vary across many other dimensions. In some cases, patients become aware of this option for care through seeing direct advertising. In other cases, organizations secure referrals from emergency departments and primary care clinicians. Some organizations only provide OUD medications whereas others also provide individual and group counseling, psychotherapy, and peer support. Some organizations mail medications directly to patients, and others require patients to pick up prescriptions at a local pharmacy. A key component of OUD treatment is laboratory testing to assess whether patients are misusing opioids. Some organizations provide patients with kits to conduct saliva or urine testing at home and ask patients to share results with clinicians via video. Other organizations refer patients to a local commercial laboratory for testing.
Recent changes to both regulations and payments for telehealth for OUD in the home have the potential to expand use of this model. To date, medication treatment using telehealth has been limited by the 2008 Ryan Haight Act (ie, the Online Pharmacy Consumer Protection Act, which was developed to regulate online prescribing and is enforced by the Drug Enforcement Administration [DEA]). This Act requires a clinician to examine a patient in person before prescribing a controlled substance such as buprenorphine, but a temporary exception has been made during the current coronavirus disease 2019 (COVID-19) pandemic. On the payment side, Medicare and many state Medicaid programs have historically not paid for telehealth visits in the home. The 2018 SUPPORT Act made several key changes. First, the act mandates a pathway, that has yet to be implemented, for telehealth clinicians to register with the DEA to prescribe controlled substances without an in-person visit. Second, the act allows Medicare patients to receive telehealth treatment for OUD in the home. In 2020, Medicare also added 3 codes under which clinicians can bill for telehealth for OUD in the home as part of bundled episodes of OUD care.
Organizations that provide home telehealth services for patients with OUD created their care models to be compliant with prior regulations, before the recent temporary exception. Some conduct an initial in-person visit with the patient, typically in a clinic or office. As such, these organizations must have a local, physical presence in the communities they serve. In contrast, when a patient is referred following presentation to a DEA-registered setting such as an emergency department, this visit “counts” as the in-person visit for the purposes of compliance, and all subsequent interactions can occur via telehealth. As this regulatory environment changes, it is possible that telehealth services for OUD in the home may proliferate because there may no longer be a need for a local, physical presence.
Serving patients with OUD in their homes has several potential advantages. One of the most important is convenience for patients. Patients usually can avoid travel, and some telehealth organizations that provide OUD treatment allow patients to schedule visits outside of business hours. As a result, this care model is more compatible with work and family obligations. The model may be particularly attractive to women with young children and individuals with mobility challenges. Second, telehealth treatment for OUD in the home could increase access to needed care. For patients in rural communities with few clinicians who have been granted waivers to prescribe buprenorphine, telehealth may be the only viable model for outpatient OUD treatment. Third, services delivered via mobile app could allow for more frequent communication with the care team (eg, text messaging with a health coach), which may facilitate adherence and improve retention. Fourth, these services may provide additional privacy and address the stigma of receiving treatment (eg, patients served at home will not be seen entering a local treatment facility). Fifth, delivering care to patients in their homes may give clinicians insight into patients’ personal lives and possibly improve the therapeutic alliance. Sixth, in a pandemic, this model supports social distancing and is likely to be the primary way patients with OUD access care for some time.
There are also potential disadvantages to telehealth in the home for patients with OUD. First, this model may be less appropriate for some patients. At present, high-risk patients including those with unstable housing or co-occurring mental illness are often screened out and referred for in-person care. Second, this care model generally requires patients to have a smartphone with a data plan and some computer literacy. Third, although the home environment is convenient, it can be chaotic. Patients may have difficulty controlling interruptions that can be distracting for both patients and clinicians. There are also privacy concerns because visits may be overheard by family members. Fourth, although many organizations advertise that they participate in insurance including Medicare, Medicaid, and commercial insurance, some fraction of patients are currently paying out of pocket for telehealth services in the home. These patients could pay between $200 and $400 per month depending on the specific program. Fifth, although studies are in progress,9 there are currently no data to demonstrate that telehealth services provided in the home for the treatment of OUD are effective. New services often are developed because of changes in payment models; hopefully they will be effective.
Given the scale of the opioid epidemic as well as new supportive regulations and sources of payment, telehealth treatment for OUD delivered at home will continue to increase. Also, the COVID-19 pandemic is likely to expand use of this model as many clinicians who treat patients with OUD are beginning to use telehealth for the first time. It remains unclear what will happen after the pandemic, both with regulation and sustained utilization of telehealth in the home. Research is needed on whether these services are comparable with in-person care on key metrics such as retention in treatment, effectiveness of long-term treatment for OUD, and cost-effectiveness. Identification of which patients are appropriate for these services is crucial for clinicians, payers, and policy makers. It will also be important to assess the extent to which the innovation reaches underserved communities. As with many telehealth innovations, growth may occur before the evidence base is strong because this new treatment model addresses a critical need and could potentially improve the care experience.
Corresponding Author: Lori Uscher-Pines, PhD, RAND Corporation, 1200 S Hayes St, Arlington, VA 22202 (firstname.lastname@example.org).
Published Online: May 27, 2020. doi:10.1001/jama.2020.3940
Conflict of Interest Disclosures: Dr Uscher-Pines reported receiving grants from the National Institute on Drug Abuse (NIDA). Dr Huskamp reported receiving grants from NIDA. Dr Mehrotra reported receiving grants from NIDA.
Funding/Support: The authors are funded by grant R01DA048533-01 from the National Institute on Drug Abuse.
Role of the Funder/Sponsor: The National Institute on Drug Abuse had no role in the preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication.
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