Addressing the opioid crisis within the Medicare population requires a multi-faceted approach.
In 2022, a staggering 83,827 Americans tragically lost their lives to opioid overdoses. Yet, despite this devastating toll, only 18 percent of the estimated 1.1 million Medicare enrollees diagnosed with opioid use disorder (OUD) received medication to treat their condition. This substantial treatment gap represents one of the many ways the opioid epidemic disproportionately affects the Medicare population.
The hard truth
The facts are sobering; very few Medicare beneficiaries needing OUD treatment are receiving it. Most individuals' perception is that OUD has a limited impact on the Medicare population. With 40 percent of Medicaid beneficiaries having an OUD, Medicare beneficiaries are often overlooked as an at-risk population. However, the OUD rate is high, especially for Medicare beneficiaries in areas with high social vulnerability. In addition, 23.5 percent of dual-eligibles have a substance use disorder.
To confront this challenge, it is important to address the obstacles preventing people from getting the help they need.
Three obstacles to overcome for Medicare patients
Coverage and cost issues: While Medicare covers certain aspects of Medication-Assisted Treatment (MAT), there may be gaps in coverage for counseling services or , prior authorization, and step therapy requirements, leading to more barriers and increased costs. In addition, coverage and cost may be dependent on where the MAT drugs are on the health plan's formulary. Not all drugs are covered, which influences efficacy and access.
Provider shortages: There is a dire shortage of healthcare providers knowledgeable about OUD treatment for the Medicare population. This leads to a scarcity of providers who are trained to prescribe an essential medication for MAT called buprenorphine, especially in rural areas. This makes it hard for patients to find the proper treatment. While telehealth has been expanded to address the provider shortage, advocating for increased telehealth utilization has the potential to significantly improve access to care in underserved areas.
Stigma: The stigma surrounding OUD and its treatment continues to be a barrier, discouraging individuals from seeking help and deterring providers from offering vital services. Reframing addiction as a treatable health condition rather than a personal failure or choice can support reducing the stigma and create a more effective whole-person, comprehensive care approach.
A practical component in providing a destigmatized personalized approach that improves patient adherence and outcomes is implementing peer support. Pairing patients with a trained peer mentor who has shared and lived experiences, such as long-term recovery, provides an example of OUD treatment success. Integrating peer support also enables assistance in social service coordination and better addresses the complex needs of those struggling with addiction.
Removing barriers
Patient-centric programs and seamless continuity of care infrastructure enable closing gaps in care for vulnerable populations, such as Medicare beneficiaries. This improves patient outcomes, performance measures, and lowers the overall cost of care. Advocating for changes built on these principles can create a healthcare system that better serves and empowers patients.
Addressing the opioid crisis within the Medicare population requires a multi-faceted approach, one that involves policymakers, healthcare providers, and community advocates working together to identify solutions and reduce barriers to treatment. It is critical to advocate for expanded access to MAT, increased provider training, and public education campaigns to combat stigma. In doing so, comprehensive OUD treatment tailored to at-risk populations and Medicare beneficiaries will be the standard.