Association of Pregnancy and Insurance Status With Treatment Access for Opioid Use Disorder | Health Disparities | JAMA Network Open | JAMA Network
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    Original Investigation
    Public Health
    August 14, 2020

    Association of Pregnancy and Insurance Status With Treatment Access for Opioid Use Disorder

    Author Affiliations
    • 1Vanderbilt Center for Child Health Policy, Vanderbilt University Medical Center, Nashville, Tennessee
    • 2Department of Pediatrics, Vanderbilt University Medical Center, Nashville, Tennessee
    • 3Department of Health Policy, Vanderbilt University Medical Center, Nashville, Tennessee
    • 4Department of Economics, Baylor University, Waco, Texas
    • 5Department of Biostatistics, Vanderbilt University Medical Center, Nashville, Tennessee
    • 6Department of Psychiatry and Behavioral Sciences, Vanderbilt University Medical Center, Nashville, Tennessee
    • 7Department of Pharmacology, Vanderbilt University Medical Center, Nashville, Tennessee
    • 8Department of Pediatrics, Ann & Robert H. Lurie Children’s Hospital and Northwestern University Feinberg School of Medicine, Chicago, Illinois
    • 9Network for Public Health Law, Los Angeles, California
    • 10Department of Obstetrics and Gynecology, Vanderbilt University Medical Center, Nashville, Tennessee
    • 11RAND Corporation, Pittsburgh, Pennsylvania
    • 12Department of Psychiatry, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
    JAMA Netw Open. 2020;3(8):e2013456. doi:10.1001/jamanetworkopen.2020.13456
    Key Points español 中文 (chinese)

    Question  Are pregnancy and insurance status associated with a woman’s ability to obtain an appointment with an opioid use disorder treatment clinician?

    Findings  In this cross-sectional study with random assignment of clinicians and simulated-patient callers, callers representing pregnant women were less likely than callers representing nonpregnant women to be granted an appointment with an opioid use disorder treatment clinician (61% vs 74%). There were substantial barriers for both pregnant and nonpregnant women attempting to gain access to treatment, including a large portion of clinicians who did not accept insurance and required cash payment for an appointment.

    Meaning  These findings suggest that pregnant and nonpregnant women face substantial barriers in obtaining appointments with an opioid use disorder treatment clinician.


    Importance  Medications for opioid use disorder, including buprenorphine hydrochloride and methadone hydrochloride, are highly effective at improving outcomes for individuals with the disorder. For pregnant women, use of these medications also improves pregnancy outcomes, including the risk of preterm birth. Despite the known benefits of medications for opioid use disorder, many pregnant and nonpregnant women with the disorder are not receiving them.

    Objective  To determine whether pregnancy and insurance status are associated with a woman’s ability to obtain an appointment with an opioid use disorder treatment clinician.

    Design, Setting, and Participants  In this cross-sectional study with random assignment of clinicians and simulated-patient callers (performed in “secret shopper” format), outpatient clinics that provide buprenorphine and methadone were randomly selected from publicly available treatment lists in 10 US states (selected for variability in opioid-related outcomes and policies) from March 7 to September 5, 2019. Pregnant vs nonpregnant woman and private vs public insurance assigned randomly to callers to create unique patient profiles. Simulated patients called the clinics posing as pregnant or nonpregnant women to obtain an initial appointment with a clinician.

    Main Outcomes and Measures  Appointment scheduling, wait time, and out-of-pocket costs.

    Results  A total of 10 871 unique patient profiles were assigned to 6324 clinicians. Among all women, 2312 of 3420 (67.6%) received an appointment with a clinician who prescribed buprenorphine, with lower rates among pregnant vs nonpregnant callers (1055 of 1718 [61.4%] vs 1257 of 1702 [73.9%]; relative risk, 0.83; 95% CI, 0.79-0.87). For clinicians who prescribed methadone, there was no difference in appointment access for pregnant vs nonpregnant callers (240 of 271 [88.6%] vs 237 of 265 [89.4%]; relative risk, 0.99; 95% CI, 0.93-1.05). Insurance was frequently not accepted, with 894 of 3420 buprenorphine-waivered prescribers (26.1%) and 174 of 536 opioid treatment programs (32.5%) granting appointments only when patients agreed to pay cash. Median wait times did not differ between pregnant and nonpregnant callers among buprenorphine prescribers (3 days [interquartile range, 1-7 days] vs 3 days [interquartile range, 1-7 days]; P = .43) but did differ among methadone prescribers (1 day [interquartile range, 1-4 days] vs 2 days [interquartile range, 1-6 days]; P = .049). For patients agreeing to pay cash, the median out-of-pocket costs for initial appointments were $250 (interquartile range, $155-$300) at buprenorphine prescribers and $34 (interquartile range, $15-$120) at methadone prescribers.

    Conclusions and Relevance  In this cross-sectional study with random assignment of clinicians and simulated-patient callers, many women, especially pregnant women, faced barriers to accessing treatment. Given the high out-of-pocket costs and lack of acceptance of insurance among many clinicians, access to affordable opioid use disorder treatment is a significant concern.