HHS Uses Grant Programs and Other Efforts to Expand Access to MAT for Opioid Use Disorders

HHS has implemented five key efforts from 2015 through August 2017  that focus on expanding access to MAT for opioid use disorders. As  the figure shows, some of these awards were made in fiscal year 2015,  while others were made as recently as May 2017. In addition to these four grant programs, HHS’s fifth key effort increases  treatment capacity by expanding the waivers that practitioners may  receive to prescribe buprenorphine. HHS is Finalizing Its Approach for Evaluating MAT Expansion Efforts but Lacks Performance Measures with Targets and Implementation Timeframes

HHS officials told us that as of August 2017, the department is in the  process of finalizing its approach for evaluating the implementation of its  agencies’ collective efforts to address the opioid epidemic that were  undertaken as part of the HHS Opioid Initiative and will continue under  the new administration’s Opioid Strategy. In  September 2016, HHS awarded a 2-year contract to Research Triangle  Institute International (RTI) to evaluate HHS agencies’ collective efforts. Increasing Access to Medication-Assisted Treatment in Rural  Primary Care Practices: Grant recipients are expected to submit  quarterly progress reports to AHRQ with various information, such as  information on the number of physicians who have been certified to  prescribe buprenorphine and the number of primary care practices  successfully initiating the delivery of MAT services as a result of the  grant project. While HHS’s evaluation will focus on whether HHS’s efforts have been  implemented as intended, officials told us that in the future an evaluation  may also focus on the effectiveness of these efforts, including the  effectiveness of efforts to expand access to MAT. HHS has some of the information that  could be used in a future evaluation of the effectiveness of its efforts to  expand access to MAT. However, HHS has not adopted specific performance measures with  targets specifying the magnitude of the increases HHS hopes to achieve  through its efforts to expand access to MAT, and by when. For example,  HHS has not established a long-term target specifying the percentage  increase in the number of prescriptions for buprenorphine HHS would like  to achieve, which would help to show whether efforts by HHS and others  are resulting in sufficient progress in increasing prescriptions for this MAT  medication. HHS has also not chosen a specific method of measuring  treatment capacity or established targets associated with it, which would  help to show whether a sufficient number of providers are becoming  available to evaluate and treat patients who may benefit from MAT. Without specifying these performance measures and associated targets,  HHS will not have an effective means to determine whether its efforts are  helping to expand access to MAT. Gauging this progress is particularly important,  given the large nationwide MAT treatment gap identified in 2015 between  the total number of individuals who could benefit from MAT and the  limited number who can access it based on provider availability. In addition, as of August 2017, HHS has not finalized its approach for the  planned evaluation activities, including timeframes. As of October 2017,  HHS had not provided a finalized evaluation approach or schedule. Federal internal controls call for management to establish and operate  monitoring activities and evaluate results. Without an implementation  timeframe for the evaluation’s activities, HHS increases the risk that its  evaluation of its agencies’ efforts will not be completed as expeditiously  as possible, including an evaluation of HHS’s efforts to expand access to  MAT. Selected Stakeholders Reported Using Outreach, Training, and Other Efforts to Help Expand Access to Medication- Assisted Treatment for Opioid Use Disorders

Officials from selected state health departments and behavioral health  agencies, private health insurers, and national associations reported  using several different efforts to help expand patients’ access to MAT for  opioid use disorders. According to the stakeholders, all five selected states have implemented  or are planning to implement a health care delivery model or approach  that will expand access to MAT. Specifically, these models or  approaches focus on integrating the use of MAT into primary care  settings. Additionally, officials from two states described  offering remote MAT-related consultations through telehealth that  connects patients in rural areas with addiction specialists. Efforts by private health insurers. Officials from three insurers reported removing prior  authorization requirements for MAT medications, thereby making it  easier for patients to access needed MAT medications more readily,  rather than undergoing a waiting period for approval to receive the  medications. Incentivizing providers and health insurance plan members to use  MAT. Officials we interviewed from the  national associations—including the American Society of Addiction  Medicine, the National Governors Association, and the Association of  State and Territorial Health Officials—told us that they are helping to  expand access to MAT through outreach and training for their members  and by developing tools and resource guides for their members. In addition, officials from one association told us that they developed an  opioid-related road map that identifies examples of strategies—including  MAT—that state policymakers can use in their ongoing efforts to address  the opioid epidemic. Examples of strategies include reducing the stigma  associated with MAT through educating the public and potential  providers. Conclusions

HHS funds grant programs and has taken other steps to expand access  to MAT, which has been shown to be effective in reducing the prevalence  of opioid use disorders and with them, the likelihood of drug overdoses. In its written  comments, HHS concurred with both of our recommendations. Specifically, for our first recommendation to establish performance  measures with targets related to expanding access to MAT for opioid use  disorders, HHS stated that developing such measures is appropriate and  that the department will continue to work to develop robust performance  measures, including measures related to MAT, as part of its overall  Opioid Strategy, which includes the department’s most recent efforts to  address the opioid epidemic.
Why GAO Did This Study

The misuse of prescription opioid pain relievers and illicit opioids, such as heroin, has contributed to increases in overdose deaths. According to the most recent Centers for Disease Control and Prevention data, in 2015 over 52,000 people died of drug overdose deaths, and about 63 percent of them involved an opioid. For those who are addicted to or misuse opioids, MAT has been shown to be an effective treatment.
GAO was asked to review HHS and other efforts related to MAT for opioid use disorders. This report (1) describes HHS's key efforts to expand access to MAT, (2) examines HHS's evaluation, if any, of its efforts to expand access to MAT, and (3) describes efforts by selected stakeholders (states, private health insurers, and national associations) to expand access to MAT. GAO gathered information from HHS officials as well as a non-generalizable selection of 15 stakeholders selected based on their MAT expansion activities, among other factors. GAO also assessed HHS's evaluation plans using internal control standards for defining objectives and evaluating results.

What GAO Found

In an effort to reduce the prevalence of opioid misuse and the fatalities associated with it, the Department of Health and Human Services (HHS) established a goal to expand access to medication-assisted treatment (MAT). MAT is an approach that combines behavioral therapy and the use of certain medications, such as methadone and buprenorphine. HHS has implemented five key efforts since 2015 that focus on expanding access to MAT for opioid use disorders—four grant programs that focus on expanding access to MAT in various settings (including rural primary care practices and health centers) and regulatory changes that expand treatment capacity by increasing patient limits for buprenorphine prescribers and allowing nurse practitioners and physician assistants to prescribe buprenorphine.
Some of the grant awards were made in 2015, while others were made as recently as May 2017. (See figure.) As of August 2017, efforts under all the grant programs were ongoing. Grant recipients can use funding to undertake a range of activities, such as hiring and training providers and supporting treatments involving MAT. In addition, certain providers and grant recipients are required to develop plans for preventing MAT medications from being diverted for nonmedical purposes.
HHS officials told GAO that as of August 2017, the department was in the process of finalizing its plans to evaluate its efforts to address the opioid epidemic. In September 2016, HHS awarded a contract to conduct the evaluation. HHS officials told GAO that they are still working with the contractor to finalize the evaluation approach and that it will focus on whether HHS's efforts to address the opioid epidemic have been implemented as intended. HHS officials said that in the future, HHS may also evaluate whether, or to what extent, its efforts have been effective in expanding access to MAT, in addition to evaluating implementation.
While HHS has some of the information that could be used in a future evaluation of the effectiveness of its efforts to expand access to MAT, it has not adopted specific performance measures with targets specifying the magnitude of the increases HHS hopes to achieve through its efforts to expand access to MAT, and by when. For example, HHS has not established a long-term target specifying the percentage increase in the number of prescriptions for buprenorphine HHS would like to achieve, which would help to show whether efforts by HHS and others are resulting in a sufficient number of prescriptions for MAT medications. HHS has also not chosen a specific method of measuring treatment capacity or established targets associated with it, which would help determine whether a sufficient number of providers are becoming available to evaluate and treat patients who may benefit from MAT.
Without specifying these performance measures and associated targets, HHS will not have an effective means to determine whether its efforts are helping to expand access to MAT or whether new approaches are needed. Gauging this progress is particularly important given the large gap identified nationwide between the total number of individuals who could benefit from MAT and the limited number who can currently access it based on provider availability.
In addition, GAO also found that as of August 2017, HHS had not finalized its approach for its planned evaluation activities, including timeframes. Without timeframes for the evaluation's activities, HHS increases the risk that the evaluation will not be completed as expeditiously as possible.
In addition to HHS efforts to expand access to MAT, officials from selected states, private health insurers, and national associations reported using several efforts to expand patients' access to MAT for opioid use disorders. For example, several stakeholders provided GAO with the following examples of their efforts:
States. State health officials from all five selected states have implemented or are planning approaches that focus on integrating the use of MAT into primary care, such as by providing services for centralized intake and initial management of patients or through telehealth that connects patients in rural areas with addiction specialists in a different location.
Private health insurers. Three private health insurers reported removing prior authorization requirements for MAT medications so patients can avoid a waiting period before receiving the medications.
National associations. Officials told GAO that they are conducting outreach and training for their members and developing tools and resource guides. For example, one association developed a road map with strategies that state policymakers can use to address the opioid epidemic, including strategies for reducing the stigma associated with MAT through educating the public and potential providers.

What GAO Recommends

GAO recommends that HHS take two actions: (1) establish performance measures with targets related to expanding access to MAT, and (2) establish timeframes for its evaluation of its efforts to expand access to MAT. HHS concurred with both recommendations.