Opinion: How to improve Maryland’s response to the opioid crisis? Reward quality of care over quantity of services

By Enrique Oviedo 

The writer is a triple board-certified psychiatrist who serves as clinical director of MATClinics.

Maryland ranks among the top five states for opioid-related overdose death rates between March 2020 and March 2021, according to data from the National Center for Drug Abuse Statistics, trailing only West Virginia, Delaware and Ohio. Overdose deaths in the state have increased at an annual rate of 5% over the last three years, resulting in more than six fatalities per day.

These grim statistics are belied by the hundreds of millions of dollars Maryland spends each year to combat the opioid crisis. The state’s fiscal 2022 budget included $978 million for mental health and substance abuse services, including $296 million for substance use disorder services, and $231.8 million for mental health and substance use disorder treatment for the uninsured.

As a result of public funds, the number of Marylanders who received any type of substance use disorder service increased by 42% between 2106 and 2020, according to a July 2022 report published by the Maryland Department of Health. Those who received buprenorphine, methadone, and other medication-assisted treatment increased by 22% for the same period.

Still, Maryland’s overdose death rate is three-and-a-half times that of its homicide rate — evidence that the state’s response to the drug crisis is inadequate. However, a bill pending before the General Assembly, Senate Bill 581, would significantly curtail overdose deaths by rewarding providers for patient results, not the number of treatment services they deliver.

The legislation would examine Maryland’s transition to a value-based reimbursement model from the current fee-for-service model. The former incentivizes providers to meet selected patient outcome measures, whereas the latter rewards quantity of services over quality of services, while failing to account for individual needs and population health goals.

I witness this directly as the medical director for MATClinics, an outpatient addiction treatment group with eight offices across the state. Each year, MATClinics provides outpatient addiction treatment to more than 3,000 patients in Maryland for substance use disorders, approximately 75% of whom are Maryland Medicaid recipients. At the expense of profitability, we have funded the development of systems that demonstrably improve outcomes for our patients.

The first system is the use of data analytics to help patients achieve recovery more efficiently — an approach we developed with scientists at the National Institute of Drug Abuse that is documented in the peer-reviewed Journal of Addiction Medicine. We allocate additional time and resources, such as intensive outpatient counseling and psychiatry, to patients who are less adherent to treatment, while transitioning those who are more adherent to less intensive visits.

MATClinics is demonstrating that data can be used on a patient-by-patient, visit-by-visit basis to improve health outcomes. Moreover, our data can be combined with other objective metrics to assess the overall quality of outcomes, including retention. Providers should be responsible for the outcomes of all their patients, not simply the ones who have achieved recovery.

The second system is the case management we provide 24/7 to each patient to help manage everyday challenges, including a lack of transportation and hectic work-life schedule, that are often barriers to recovery. Because the lives of those with a substance use disorder are too often in disarray, roughly three-quarters of our patients use these services. By helping patients manage their everyday lives, recovery is more manageable for them.

Despite their significant benefits to patients, however, MATClinics’s investments in these systems are completely ignored by Maryland’s fee-for-service model. Because it is unrealistic for any business to invest in a service for which it receives no compensation, the state is missing an essential opportunity to improve its response to the opioid crisis by incentivizing providers to innovate systems that can save lives.

Maryland lawmakers should take note of the 22 state Medicaid programs (and counting) that require plans to implement value-based reimbursement for behavioral health services, including treatment of substance use disorders. Emphasizing the quantity of services over the quality of care in addiction treatment has proven far too costly for far too long.