Expanding Access to Methadone Treatment for Opioid Use Disorder: Measurement and Policy Considerations for the...

To establish methods for comparing Department of Veterans Affairs (VA)-direct and VA-purchased "community care" (CC) for methadone medication for opioid use disorder (M-MOUD), and determine differences in access, quality, and cost.

Three outcome measures were constructed: wait times (from clinician referral to appointment) for access, retention on M-MOUD (number of months, from one to six) for quality, and 6-month treatment costs (M-MOUD and related services). We used generalized linear models to estimate differences in each outcome for CC versus VA.

VA electronic health record and CC claims. Our study included VA patients referred by clinicians for M-MOUD between April 1, 2023-March 31, 2024 in VA (n = 389) and CC (n = 219) and, secondarily, VA walk-ins (n = 1830).

Average unadjusted wait times from clinician referral to appointment were 15.73 days (standard deviation [SD] = 16.27) in VA and 19.03 days (SD = 19.12) in CC, while there was no wait time for Veterans seen as VA walk-ins. Average unadjusted M-MOUD retention was 2.07 months (SD = 1.65) in VA and 3.13 months (SD = 1.84) in CC. Average unadjusted 6-month costs were $7360 (SD = $9554) in VA and $4376 (SD = $2171) in CC. In adjusted models, CC had greater M-MOUD retention (1.07 months longer, p < 0.0001) and lower costs ($-1720, p < 0.05) compared to VA clinician referral; wait times did not statistically differ (p = 0.12). M-MOUD retention and cost patterns did not change when considering VA walk-ins.

An important option for expanding Veterans' access to M-MOUD is through CC. In this group of Veterans receiving M-MOUD, CC retention was greater and costs were lower. However, CC lacks the walk-in option for same-day access. This signals tradeoffs to consider when assessing the balance between VA and CC and provides methods for comparing VA and CC treatment options.