Opioid overdose patients with private insurance are rarely connected to addiction treatment after visiting the emergency department, a new national study from the University of Pennsylvania has found.
And the problem is particularly severe among black and Hispanic patients, more evidence of deep racial disparities in health care generally and addiction treatment in particular.
Private insurance — which most Americans get through employers — is a marker of relative affluence. So this study finds, as others have, that race and not poverty can spell the difference in getting needed care.
The study, released Wednesday, examined a large private insurer’s records for more than 6,500 opioid overdose patients who were treated at an emergency department between 2011 and 2016.
In the three months after their overdoses, less than 17% received follow-up treatment, defined as a pharmacy claim for medication-assisted therapy, or a medical claim for a visit to outpatient or inpatient treatment. Less than half of all patients who got follow-up treatment received anti-addiction medication, considered the gold standard of care.
“This study shows that even people with insurance may still have barriers to treatment,” said Austin Kilaru, the study’s lead author, an attending physician at Penn Presbyterian Medical Center, and a fellow in the National Clinician Scholars Program at Penn. “Just the fact of having insurance may not empower you to make the leap [to treatment].”
Black patients were half as likely as white patients to receive such treatment. Hispanic patients were also less likely than white patients to get treatment.
Kilaru called those data “the most important finding of this paper.”
He said he and his coauthors wanted to study privately insured Americans, as opposed to people on Medicaid, because they wanted to see whether private insurance might level out racial disparities in access to health care.
“We think of patients with Medicaid generally having worse access to care because of their insurance, especially around substance use treatment," he said. "There are more minorities in the Medicaid population, and we were wondering whether you could correct those disparities if you gave patients an even playing field with the kind of insurance they had. That wasn’t the case.”
It’s difficult to tell what is driving the racial disparities found in the study, Kilaru said. It might be that minority patients are less likely to seek treatment, or that doctors’ bias plays a role, or that other barriers are keeping patients, especially minorities, from getting prompt treatment.
Still, the authors wrote, “it is important to better understand and account for these factors when designing systems that seek to improve engagement and equity in treatment.”
It’s also hard to tell how many of the patients examined in the study were addicted to opioids, as opposed to patients who accidentally overdosed on prescribed pain medication. Patients who had been in addiction treatment before their overdose were more likely to seek it again afterward, Kilaru said.
In addition, the insurer examined in the study didn’t cover methadone, the opioid-based addiction treatment that’s one of the most common medications for opioid use disorder. It usually is administered at publicly funded centers, not through private medical practices.
“We cannot account for patients who pay for opioid use disorder treatment out-of-pocket,” the study authors wrote, including those who paid for their own methadone.
Kilaru said busy ER doctors need to be compensated for the time it takes to discuss treatment options and then arrange for outpatient care.
“When I work in the ED, I only get compensated for the care I provide there,” he said. “The outpatient providers only get reimbursed for the care they provide in the outpatient setting. There’s no financial incentives to encourage that coordination, that crossing over from myself to another provider.”