Misalignment of Stakeholder Incentives in the Opioid Crisis
Abstract
:1. Introduction
- Regulations on reimbursement policies, such as the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) survey, which partially rewards healthcare systems and providers when patients score high on pain management experience of care, thus making providers more inclined towards opioid analgesics [4];
- Lack of a comprehensive multi-modal pain management strategy [5];
- Barriers in adopting treatments for opioid /substance use disorders [6];
2. Methods
- Category 1: “opioid”.
- Category 2: “alignment”, “misalignment”, “align”, “misaligned”, and “incentive”.
- Category 3: “stakeholder”, (“societal planner”, “payer”, “insurer”, “insurance”, or “coverage”), (“payment”, “reimbursement”, “fee-for-service”, “capitation”, “capitated”, “pay-for-performance”, “bundled payment”, “accountable care”, or “value-based”), (“provider”, “physician”, or “hospital”), “patient”, (“employer” or “employment”), (“pharmaceutical” or “drug”), (“pharmacologic”, “non-pharmacologic”, or “nonpharmacologic”), (“barrier” or “facilitator”), and (“contingent” or “contingency”).
3. Results
3.1. Stakeholder Misalignment Before Onset of OUD/SUD: A Prevention Perspective
3.1.1. Payment Mechanisms, Reimbursement Schemes, and Incentives
3.1.2. Practice Guidelines and Healthcare System Structures
- Providers do not have a clear idea about how to easily implement these guidelines in their practices or there exist uncertainties surrounding the impact of the recommendations on patient pain levels, particularly in the presence of comorbidities [27].
- Across different specialties/medical conditions, (i) there is no consensus among providers in selecting optimal treatments, and (ii) there are various perspectives on how opioids are deemed appropriate, resulting in many of the providers not aligning with the guidelines and/or significant variations among them in opioid prescription [28,29,30]. On a similar note, emergency departments (EDs) are shown to be more aligned with the CDC guidelines than non-EDs [31].
3.1.3. Multi-Modal Pain Management
3.1.4. Initiatives for Opioid Prescription/Side Effects Reduction
3.1.5. Physician-Patient Shared Decision Making
3.2. Stakeholder Misalignment After Onset of OUD/SUD: An Intervention Perspective
3.2.1. Barriers in Adopting Treatments
3.2.2. Facilitators to Adopting Treatments
4. Discussion
- Payers, providers, and patients due to conventional payment mechanisms such as FFS and capitation, lack of proper insurance coverage for multi-modal pain management, and system structures such as dual drug benefit programs for VA and Medicare Part D enrollees resulting in care fragmentation;
- Policy makers and providers due to guidelines that are not easily translatable for implementation in practice;
- Providers and patients due to lack of shared decision making on treatments, which is also common in the intervention stage.
- Payers, providers, and patients due to lack of proper insurance coverage for OUD/SUD treatments, the limited number of providers for prescribing treatments, and lack of effective incentives and reimbursements for providers;
- Pharmaceutical companies, payers, and patients due to the high cost of medications;
- Providers (PCPs and specialists) due to care fragmentation and lack of proper guidelines to streamline pathways for patients.
- (1)
- The co-occurrence of OUD/SUD and chronic pain can impose pressure on providers due to multi-layered and complex treatment requirements, lack of patient improvement for either condition, and care fragmentation caused by ineffective pain management referrals [6].
- (2)
- Guidelines that promote curbing the supply of opioids may have unintended consequences such as the increase in the number of deaths caused by fentanyl misuse. In the presence of conflicting interests, one can investigate how facilitating aligning incentives can contribute to remedying such effects.
- (3)
- Stigma and discrimination against people with concurrent OUD/SUD and mental health disorders can stymie an effective care delivery process [132].
- (4)
- Although incurred medical expenditures for OUD/SUD would be higher than that for under-treated pain [133], employers’ cost of lost productivity would not be much different, because their employees could miss work due to both OUD/SUD and unrelieved pain [134,135]. Hence, the role of employers should not be limited to expanding access to OUD/SUD treatments. Indeed, employers’ contribution to employment-based insurance coverage would impact the availability of treatment options and the cost of prescription drugs [136], which, in turn, affects pain management outcomes.
- (5)
- Strategies like contingency management, aimed at improving OUD/SUD treatment adherence and retention in opioid substitution programs, have been reported to be effective only in the short term (due to financial/resource limitations), and their efficacy over the long term is yet to be investigated [137].
- (6)
- The timing of initiating OUD/SUD treatments is a deciding factor in their success. However, patients at higher risk may not be always easy to identify. To address this, one can benefit from points of access to patients to potentially initiating treatments. These include ED visit/hospital admission [138,139,140,141,142] and incarceration [143,144,145,146,147,148,149]. Employing techniques like screening, brief intervention, and referral to treatment (SBIRT) can also be helpful in this regard [75].
- (7)
- (8)
- As a result of opioid consumption ramping up during the COVID-19 pandemic [9,10], the long-term rates of OUD/SUD can be impacted as well, which can inevitably aggravate misaligned incentives. In addition to the avenues discussed thus far, this is another stream that warrants further investigation and knowledge production.
5. Conclusions
Author Contributions
Funding
Conflicts of Interest
References
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Stage | Topic | Studies | Stakeholders | Misalignment Source | ||||||
---|---|---|---|---|---|---|---|---|---|---|
PY | PR | PT | PM | OT | Cost | Quality | Access | |||
Prevention | Payment Mechanisms, Reimbursement Schemes, and Incentives | [4,15,16,17,18,19,20,21,22,23,24,25,26] (13: 2010–2019) | ✓ | ✓ | ✓ | — | — | ✓ | ✓ | — |
Practice Guidelines and Healthcare System Structures | [27,28,29,30,31,32,33,34,35] (9: 2010–2019) | — | ✓ | ✓ | ✓ | — | — | ✓ | ✓ | |
Multi-Modal Pain Management | [21,36,37,38,39,40,41,42,43,44,45,46,47,48,49,50,51,52,53] (1: 2000–2009, 18: 2010–2019) | ✓ | ✓ | ✓ | — | — | ✓ | ✓ | ✓ | |
Initiatives for Opioid Prescription/Side Effects Reduction | [54,55,56,57,58,59,60,61,62,63,64,65,66,67,68,69] (16: 2010–2019) | ✓ | ✓ | ✓ | — | — | ✓ | ✓ | ✓ | |
Physician-Patient Shared Decision Making | [70,71] (2: 2010–2019) | — | ✓ | ✓ | — | — | ✓ | ✓ | — | |
Intervention | Barriers in Adopting OUD/SUD Treatments | [72,73,74,75,76,77,78,79,80,81,82,83,84] (2: 2000–2009, 11: 2010–2019) | ✓ | ✓ | ✓ | — | ✓ | ✓ | ✓ | ✓ |
[77,80,81,82,85,86,87,88] (2: 2000–2009, 6: 2010–2019) | — | ✓ | ✓ | — | — | ✓ | ✓ | ✓ | ||
Facilitators to Adopting OUD/SUD Treatments | [89,90,91,92,93,94,95,96,97,98] (10: 2010–2019) | ✓ | ✓ | ✓ | ✓ | — | ✓ | ✓ | ✓ | |
[74,99,100,101,102,103,104,105,106,107,108,109,110,111,112,113,114,115,116,117,118,119] (6: 2000–2009, 16: 2010–2019) | ✓ | ✓ | ✓ | — | — | ✓ | ✓ | ✓ | ||
[120,121,122,123,124,125,126,127,128] (3: 2000–2009, 6: 2010–2019) | — | — | ✓ | ✓ | ✓ | ✓ | ✓ | ✓ |
Term | Description |
---|---|
Stakeholder | An entity who plays a role in navigating a healthcare-related problem, e.g., payer, provider, patient, employer, pharmaceutical company, etc. |
Incentive | An interest for a stakeholder, e.g., monetary (revenue), health-related (quality of life), political (implications of a proposed healthcare bill), organizational (e.g., integrity and power issues), or behavioral (e.g., psychological factors). |
Misalignment | A condition caused by competing and/or conflicting interests between two or more stakeholders resulting in either an increase in the cost of care, a reduction in the quality of care, or less access to care. |
Alignment | A condition where devising mechanisms among stakeholders can either lower the cost, improve the quality, or enhance the access to care. This is a relative notion in that a “complete” alignment may not be attainable in reality. |
Fee-for-service | A payment mechanism where a provider is separately reimbursed for every service delivered to a patient. |
Capitation | A payment mechanism where a provider is reimbursed per patient per time period. |
Pay-for-performance | The general class of payment mechanisms where the provider(s) is reimbursed based on the quality of care delivered to patients. Some examples include “bundled payment” and “accountable care”. |
Bundled payment | A payment mechanism where a bundled payment is paid to a group of providers per patients per episode of care. |
Accountable care | A payment mechanism where a group of providers shares benefits/savings (upon high-quality delivery of care) or is penalized in reimbursements otherwise. |
Managed care | Health insurance plans that provide care for enrollees at lowered cost. Different types include health maintenance organizations, preferred provider organizations, and point of service. |
Care fragmentation | Care that is delivered to a patient via multiple providers while there is little to no coordination between providers. |
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Boloori, A.; Arnetz, B.B.; Viens, F.; Maiti, T.; Arnetz, J.E. Misalignment of Stakeholder Incentives in the Opioid Crisis. Int. J. Environ. Res. Public Health 2020, 17, 7535. https://doi.org/10.3390/ijerph17207535
Boloori A, Arnetz BB, Viens F, Maiti T, Arnetz JE. Misalignment of Stakeholder Incentives in the Opioid Crisis. International Journal of Environmental Research and Public Health. 2020; 17(20):7535. https://doi.org/10.3390/ijerph17207535
Chicago/Turabian StyleBoloori, Alireza, Bengt B. Arnetz, Frederi Viens, Taps Maiti, and Judith E. Arnetz. 2020. "Misalignment of Stakeholder Incentives in the Opioid Crisis" International Journal of Environmental Research and Public Health 17, no. 20: 7535. https://doi.org/10.3390/ijerph17207535