Implementation of a state financial incentive policy to improve emergency department treatment of opioid use disorder: a qualitative study

Abstract

Objective

In 2019, Pennsylvania established a voluntary financial incentive program designed to increase the rate of addiction treatment for Medicaid patients with opioid use disorder following emergency department (ED) encounters. In this qualitative study of hospital leaders, the authors examined decisions leading to participation in the program, as well as barriers and facilitators that influenced its implementation.

Methods

Semi-structured interviews were conducted with leaders from a diverse sample of hospitals and health systems across Pennsylvania. Interviews were planned and analyzed following the Consolidated Framework for Implementation Research (CFIR). An iterative approach was used to analyze interviews and determine key themes and patterns regarding implementation of this policy initiative in hospitals.

Results

The authors identified six key themes that reflect barriers and facilitators to hospital participation in the program. Participation in the program was facilitated by 1) community partners capable of arranging outpatient treatment for opioid use disorder, 2) incentive payments focusing hospital leadership on opioid treatment pathways, 3) multi-disciplinary planning, and 4) flexibility in adapting pathways for local needs. Barriers to participation in the program were 5) challenges to implementation of buprenorphine prescribing, and 6) difficulties in following and measuring patient outcomes.

Conclusions

A financial incentive policy induced hospitals to enact rapid system and practice changes to support treatment for opioid use disorder, although challenges remain in implementing evidence-based treatment for ED patients. Analysis of patient outcomes is needed to further evaluate this policy initiative, but new delivery and payment models may improve systems to care for opioid use disorder.

INTRODUCTION

Financial incentives have not been widely implemented to improve and expand the treatment of opioid use disorder, although they have been shown to be effective.^1,2 Value-based payment models are emerging to support substance use disorder treatment in the form of pay-for-performance, health homes, and accountable care organizations.^2–8 Incentives for clinicians have increased prescribing of medication treatments, such as buprenorphine.⁹ However, hospitals have not received inducements to provide or expand access to treatment for opioid use disorder.

Hospital emergency departments (EDs) not only care for patients with overdose and other complications from opioid use - they also serve as vital touchpoints to engage patients into longer-term addiction treatment.^10–14 Following an overdose, patients are at risk for repeat overdose and death.^15,16 Initiation of buprenorphine in the ED improves patient outcomes and retention in treatment.^17,18 Patients also benefit from navigation and counseling during the vulnerable transition following hospital discharge, an approach described as a ‘warm handoff.’^19,20

Policymakers have recognized that strengthening the linkage from the ED to treatment is an opportunity to combat the opioid epidemic.¹⁴ Patients obtain follow-up treatment at low rates following emergency care, including low rates of initiation of medications such as buprenorphine.^21–24 Several states have developed guidelines, regulations, and initiatives to facilitate linkage to treatment.²⁵ For example, Massachusetts mandates that hospitals provide specialized evaluations for ED patients and arrange transitions for patients that express interest in treatment.²⁶ In contrast, Pennsylvania chose to create a financial incentive program for hospitals.²⁷ The Department of Human Services (DHS), in collaboration with the Hospital and Healthsystem Association of Pennsylvania (HAP), established the Opioid Hospital Quality Improvement Program (HQIP) in 2019, after an 80 percent increase in ED encounters for opioid overdose in preceding years.^13,28 The program seeks to increase the rate of follow-up treatment for Medicaid patients within 7 days of an ED encounter for opioid-related illness.

The Opioid HQIP consists of two phases.²⁸ The first phase offers a one-time process incentive for hospitals that attest to implementing four distinct treatment pathways. The pathways are: 1) initiation of buprenorphine treatment during the ED encounter, 2) warm handoff to outpatient treatment, 3) referral to treatment for pregnant patients, and 4) inpatient initiation of methadone or buprenorphine treatment. Payment of the full incentive was contingent on participation in all four pathways, with stepwise payments for partial participation: $25,000 for one pathway per hospital, $62,000 for two, $108,000 for three, and $193,000 for all four, although the final amounts were higher due to outstanding funds allocated for this purpose. No penalties were associated with this program. The second phase of the program, begun in 2020, consists of annual performance incentives as determined through analysis of Medicaid claims. All Pennsylvania hospitals are eligible for performance incentives regardless of participation in the first phase.

The objective of this study was to evaluate implementation of this state policy to create financial incentives for hospitals focused on opioid use disorder. We examine how hospitals made the decision to participate in the first phase of the Opioid HQIP, with attention to barriers and facilitators for implementing treatment pathways. We used qualitative methods to examine operational, cultural, and financial influences on the implementation of this program, to gain insight into how such incentives may be modified and extended to other settings.

STUDY DATA AND METHODS

Sample and Participant Recruitment

We conducted semi-structured interviews with hospital leaders across Pennsylvania. We obtained obtain a broad representation of hospitals in the state, with regard to key characteristics including location, size, and health system affiliation (Exhibit 1). We purposively sampled study hospitals from a publicly available, comprehensive list of Pennsylvania hospitals stratified by participation status.²⁸ We excluded pediatric, specialty, and federal hospitals. We obtained data on hospital characteristics from the Pennsylvania Department of Health. Hospitals varied with respect to their level of participation in the process incentive; hospitals were either full participants (adopted all four treatment pathways), partial participants (adopted between one to three), or non-participants (adopted none).

Interview participants were selected among hospital and health system leaders who had direct involvement in the decision to participate in the program as well as its implementation. These stakeholders varied between institutions and included chief medical and operating officers, directors of behavioral health, addiction medicine specialists, ED chairs, and physician-leaders. Study hospitals nominated interview participants who were then approved by the study team after reviewing their role at the hospital; in two instances, the study team requested an alternate participant. Some interviews included multiple participants although primary respondents were specified in advance. Initial recruitment inquiries were conducted over email with assistance from HAP. Telephone interviews occurred from April to June 2019, following the participation deadline for the process incentive (March 2019). All interviews were conducted by a single study author (ASK). The mean interview length was 48 minutes (range 29 – 74).

Interview Procedures

We developed the interview guide using the Consolidated Framework for Implementation Research (CFIR).^29,30 The CFIR model draws from multiple evidence-based theories to offer a unified and practical framework for organizing various influences on implementation (constructs).²⁹ The primary goal for the interviews was to understand the willingness of organizations to engage in this financial incentive program, with focus on barriers and facilitators to implementing opioid treatment pathways.

The research team designed open-ended interview questions to allow for inductive examination of the decisions, experiences, and processes that occurred in hospitals when considering HQIP participation. Questions were framed according to the CFIR constructs that were identified as most relevant to study objectives, including implementation climate, culture, and readiness for implementation (inner setting); design quality and packaging (intervention characteristics); planning, engaging, and executing (process); and external policies and incentives (outer setting).³⁰ We also included questions to deductively examine specific a priori hypotheses for potential influences on HQIP participation, based upon literature review as well as quantitative analysis of hospital participation in the program.²⁷ We revised interview questions iteratively after piloting the guide within the authors’ home institution and after each of the first three study interviews.

The research team assessed saturation after each set of three interviews, through review of the transcript and preliminary notes. Saturation was defined as informational redundancy, or the point at which new data was redundant of data previously collected.^31,32 We determined that saturation was achieved after 15 interviews; 5 additional interviews were completed to ensure broad representation of hospitals in the sample. Saturation of data was assessed across all hospitals, regardless of participation status.

Analysis

Interviews were recorded, transcribed verbatim, cleaned, and entered into NVivo, a qualitative analysis software package. We created a preliminary codebook, with individual codes representing specific CFIR constructs that were included in the interview guide.³⁰ Using a qualitative content analysis approach, two authors trained in qualitative techniques (SFL and JD) systematically coded interviews using NVivo.^33–35 The first five transcripts were independently double-coded, with greater than 95 percent agreement on each transcript. The study team discussed discrepancies, and the codebook was refined through an iterative process that added emergent codes, standardized code definitions, or removed unnecessary codes. After the remaining interviews were coded, interview responses with attributed codes were extracted and analyzed in discussion by the study team. Key patterns and themes were assembled by the research team through a consensus process. Analysis was pooled for hospitals with varying participation status, but we additionally examined trends in themes according to participation status in an exploratory analysis. The Institutional Review Board at the University of Pennsylvania approved this study. The study team followed the Consolidated Criteria for Reporting Qualitative Research (COREQ) in the conduct of this study.³⁶

STUDY RESULTS

Characteristics of Study Participants

We completed 20 interviews across different hospitals and health systems in Pennsylvania. Characteristics of these organizations are presented in Table 1. Study hospitals varied with respect to key characteristics, including location, size, profit status, and health system affiliation. Of the hospitals included in this study, 7 were full HQIP participants, 7 were partial participants, and 6 did not participate. The roles of specific interview participants are shown in Table 2. Interviewees varied with respect to their position in the organization, although all had a direct role in adoption and implementation of the opioid treatment pathways.

Table 1.

Characteristics of study hospitals in comparison to all eligible Pennsylvania hospitals

Hospital characteristics	Study Hospitals (n = 20)		Eligible Pennsylvania hospitals (n = 155)
	n	%	n	%
Bed size, (M ± SD)	275 ± 190		208 ±198
Location
Urban	15	75	114	74
Rural	5	25	41	26
Teaching status
Teaching	13	65	86	55
Not teaching	7	35	69	45
Tax Status
Not-for-profit	18	90	145	94
For-profit	2	10	10	6
Health system affiliation
Independent	6	30	28	18
≥2 hospitals	14	70	127	82
State region
Southeastern	5	25	47	30
Northeastern	3	15	22	14
Central	6	30	33	21
Western	6	30	53	34
HQIP participation
Full participant	7	35	79	51
Partial participant	7	35	45	29
Non-participant	6	30	31	20
HQIP participation, by pathway
ED initiation of buprenorphine	9	45	93	60
Warm handoff to outpatient treatment	14	70	124	80
Pregnancy referral	12	60	118	76
Inpatient initiation of medication treatment	11	55	93	60

Table 2.

Role of primary interview respondent and HQIP participation status, by study hospital

Hospital	Role of primary interview respondent	HQIP participation
1	Associate executive director	Full
2	Chief medical officer	Full
3	Chief of emergency department	Full
4	Chief operating officer	None
5	Chief of addiction services	Partial
6	Chief medical officer	Full
7	Chair of emergency medicine	Full
8	Director of case management	None
9	Medical director	Full
10	Chief operating officer	None
11	Medical director of addiction medicine	Full
12	Director of behavioral health	Partial
13	Chief medical officer	None
14	Director of quality	Partial
15	Medical director of emergency department	Partial
16	Director of behavioral health	Partial
17	Chief quality officer	None
18	Medical director of emergency department	Partial
19	Assistant medical director of emergency department	None
20	Chief of emergency department	Partial

Key Themes

Table 3 summarizes six key themes that emerged from the interviews, along with representative quotations. These themes are mapped to specific CFIR constructs that were used as the framework for the interview guide and data analysis. The Online Supplement Table additionally presents trends for these key themes with regard to hospital participation status.

Table 3.

Representative Quotations for Key Themes

Theme	CFIR Constructs	Representative Quotations
1. Resources and Community Partnerships	Inner setting (readiness for implementation)	We’re a single, stand-alone independent hospital. We were just not big enough to support own MAT treatment at this point. As individual providers, we can consider MAT, but we have to rely on other players for the next steps after ED departure. (Hospital 3; full participant)
1. Resources and Community Partnerships	Outer setting (patient needs and resources)	Previously we had very limited resources in our community, due to our rural nature. But recently, there has been a lot more development of resources and support in our area. We have___that reached out to us, and we partnered with them to do the warm handoff where we refer patients to them while they are in the ED. They would send a representative out 24/7 to interview the patient in the ED. (Hospital 18; partial participant)
1. Resources and Community Partnerships	Intervention characteristics (cost)	We have a [external] grant, and they have dollars to put towards drug and alcohol counseling for people. Just thinking in terms of what other hospitals would need, I think the inpatient drug and alcohol counselors that we utilize, I don’t think a lot of other hospitals would have the resources to hire them. (Hospital 2; full participant)
2. Organizational Priorities and Funding	Inner setting (readiness for implementation)	I said we should do it for two - well, three reasons. One, it was consistent with what we had wanted to do. Two, there was money associated with it, theoretically - although we were not sure if we would ever see any of the money. Three, it did, it raised the issue to a level of, ‘Hey, the Department of Health cares enough about this. We’ve got to do this not just because it’s the right thing, but because we’re a pledged program. (Hospital 9, full participant)
2. Organizational Priorities and Funding	Inner setting (implementation climate)	Once we figured out that there was no penalty - well screw it - let’s do it anyway. If we get the reward for it, great. If we don’t, we’ll still keep doing what we’re doing. Once we took the pressure off ourselves and all the minor details, we could just get to work and work through it.... (Hospital 3; full participant)
2. Organizational Priorities and Funding	Outer setting (external policies and incentives)	I think it’s helpful to have that financial tie to it. I’d like to believe that we would have done this regardless. But we didn’t have resources before for this, and [external community partner] reached out to us pretty much at the same time. When we saw that there was an opportunity, of course, that spurred us to take advantage as well. (Hospital 18; partial participant)
3. Buprenorphine Practice Changes	Inner setting (culture, implementation climate)	“I think that the stigma about buprenorphine - it took some lobbying on my behalf, a little education of the docs about it. I had to say ‘People are not going to come here every day for their [buprenorphine]. Like this is a one-time deal. They’re not coming in to abuse it, there’s not going be a [buprenorphine] clinic or whatever… Once you laid it out and educated them, then we created an algorithm and protocol and order set, so that it’s fairly easy to do.” (Hospital 19, non-participant)
3. Buprenorphine Practice Changes	Characteristics of individuals (knowledge and beliefs about the intervention); Intervention characteristics (design)	“The ER physicians had been very reluctant to become certified for [buprenorphine]. I know there’s a three-day or four-day waiver course, but whatever the problem is - we only locally have one or two clinics which take medical assistance patients. So, three of the four pathways were out. That left us with the fourth - with the one. And that is something we are already doing.” (Hospital 13, partial participant)
4. Coordinated Planning and Champions	Process (planning)	We have broad representation from the health system, again through our ED department, our pharmacy, our OB unit… across the health system of individuals who work in the departments that are caring for these patients, as well as representation from a lot of other community organizations, again that touch the opioid issue. We were identifying this as an opportunity, long before this quality program presented itself. (Hospital 2, full participant)
4. Coordinated Planning and Champions	Process (engaging, champions)	Again, this policy flowed first to our operational leaders. They were aware of it because we talked broadly about our strategic plan in the system, and they were able to quickly hand it off to a group that was able to do something about it. It could be handled at a system level as opposed to being done hospital by hospital. (Hospital 9, full participant)
5. Program Design and Clarity	Intervention characteristics (design quality and packaging, adaptability)	It was difficult trying to put a protocol in place for a system that could provide that level of coverage, with varying degrees of community - or lack of community - resources. And it was difficult not really having the pathways clearly defined. It made it difficult to put something on paper for what our protocol would be - that would successfully meet what DHS is asking for. (Hospital 16, partial participant)
6. Technology and Data Collection	Process (reflecting and evaluating)	[The community treatment facility] sends us an excel spreadsheet. But a lot of times the data is inaccurate, and it’s not followed through. There is a lot of gaps in it and I’m not sure from their end who is responsible for collecting that and entering that data into the excel spreadsheet. (Hospital 18, partial participant)
6. Technology and Data Collection	Inner setting (readiness for implementation)	We’re finding [outcomes] very difficult to capture, partially because of our own EMR limitations through our own health system. Really being able to know about patients that we engage - how many have we successfully gotten into inpatient treatment or have a seven-day follow-up? Without getting numbers from the state, any insurers to say, ‘This percentage has had an encounter within 7 days of an ED visit.’ We’re having a really difficult time trying to capture that to see how successful we’re being. (Hospital 16, partial participant)

Resources and Community Partnerships

Implementation of HQIP opioid treatment pathways required resources; specifically, trained staff to counsel patients and coordinate follow-up care. The presence of in-person recovery specialists or case managers, although not specifically mandated by the program, was thought to be effective in ensuring successful care transitions: “Having [Certified Recovery Specialists] sitting in the ED, and in other cases on-call, available to just step in with those cases, is why folks think positively about the warm hand-off program, because there is someone trained in how to deal with them” (Hospital 5, partial HQIP participant).

However, most hospitals were unable to justify investing in these resources internally, specifically smaller or independent hospitals with lower volumes of patients with opioid use disorder. Some hospitals noted resources as a barrier to participation - despite the incentive payments: “We would have to add additional ER staff to manage a small population. We already staff that department pretty lean. We really don’t have the resources. I know that there is funding, but I don’t know if that is worth being spent on a small segment of our population” (Hospital 10, non-participant).

For several hospitals, the strategy for overcoming resource limitations was partnership with external community organizations. These relationships were cited as necessary for hospitals to participate in the HQIP. Two key characteristics described these community partners: geographic proximity and proactive engagement with patients. For example, effective partners were able to provide in-person consultation to patients. Community partners could guarantee destinations for patients to receive care following discharge from the hospital, reassuring willing providers who lacked experience with buprenorphine treatment: “Our relationship with a behavioral health organization that is literally steps away from our ED is really key to success. We like to work in partnership with them because they are really the experts” (Hospital 20, partial participant).

In many cases, community partners were those that had been designated as ‘Single County Authorities’ (SCA) or ‘Centers of Excellence’ by the state of Pennsylvania, who receive separate funding to support opioid treatment and assume local responsibility for navigating patients to care. While some hospitals described these external services as robust, there was variation in the quality and alignment of services. For hospitals and health systems that did provide internal addiction services, they pursued external grant funding which created concerns for sustainability.

Organizational Priorities and Funding

All hospital representatives expressed interest in developing initiatives to improve treatment for opioid use disorder, but some had to balance participation in this program with competing priorities, including other opioid-related initiatives such as improving prescribing behavior: “I think the goal of the program is great. But jumping to, ‘We’re going to focus on getting people from the hospital into therapy’ - I didn’t think we were ready to start. This was putting the cart before the horse … we had to think about prescribing [first]” (Hospital 4, non-participant).

For many hospitals, the Opioid HQIP focused organizational attention on this specific issue. Many leaders interpreted the policy as an endorsement from the state that this problem was urgent and should be prioritized over others. In many cases, the existence of the policy allowed internal champions to proceed with existing plans that had yet to be implemented: “I thought a lot of these things were important to be doing anyway. But because of the lack of resources behind them, it was hard to get momentum to really push them forward. Not that people were resistant. It’s just that people have jobs. It’s hard to fit it in to everything else you’re required to do…Our Chief Quality Officer was onboard very quickly, and then the financial benefits brought along the CFOs” (Hospital 11, full participant).

In most cases, the financial incentive provided additional momentum for efforts to improve access to treatment for opioid use disorder. However, pledged incentives were not incorporated into hospital budgets. More than the specific amount of funding, the fact that the program was tied to any funding encouraged hospital participation: “It was something that we were going to do anyway in terms of starting the program. But I felt like any time there’s a financial incentive or something, I think the administration would be more likely to support our projects, so I thought that would be helpful. It was financial reinforcement of the original motivation for what we wanted to do” (Hospital 15, partial participant).

Buprenorphine Practice Changes

One treatment pathway focuses on the initiation of treatment with buprenorphine by an ED provider. All partially participating hospitals chose to not implement this specific pathway. Although there was interest in introducing buprenorphine to the ED setting, several participants noted operational and cultural barriers, including physician training. Buprenorphine prescribing requires special training and approval of a specific waiver from the Drug Enforcement Agency (DEA), known as the DATA 2000 or “X” waiver. As a physician-leader noted, “There’s not an emergency department that doesn’t want to have [crisis recovery specialists], and yet when you go to them and say - ‘we can train your doctors to prescribe buprenorphine, it will be free - just bring them in.’ Nobody shows up...We need more education, and yet you provide the education, and nobody is there” (Hospital 5, partial participant).

Participants noted perceived concerns that buprenorphine prescribing would lead to increased use of the ED as a primary site for addiction treatment. As one department chair said, “I took the lead, started prescribing [buprenorphine] and these people didn’t come back the next day or the day after that. I was able to show people this - and now maybe half of my [providers] are at least comfortable giving [buprenorphine] in the ED. I’m the only one who is X-waivered, though” (Hospital 3, full participant). Hospital leaders noted that stigma remained a barrier to changing practice among the clinical staff, including ED physicians and nurses. A director of behavioral health said that “The emergency physicians are not starting [buprenorphine]. They’re totally philosophically against that, actually. They will use benzos for these patients, but they will not start [buprenorphine]” (Hospital 8, non-participant).

Coordinated Planning and Champions

Hospital leaders described an extensive process of planning treatment pathways when considering whether to participate in the program. Planning required involvement of multiple stakeholders, including representatives from the ED, behavioral health, addiction medicine, pharmacy, obstetrics, hospital medicine, nursing managers, and hospital administration including financial officers. Health systems with multiple hospitals also engaged in planning across different facilities. In most cases, hospitals attempted to balance consistent implementation across the health system with the particular circumstances of individual hospitals and local communities. Many health systems decided to collectively participate at a certain level but allow for local adaptation: “Our goal at the beginning was that all hospitals would be able to attest to all four. Also, our approach was to go to each hospital emergency department and hospital leadership to identify at least one or more champions from their facility to be able to participate, so we could discuss implementation, barriers, share best practices, what worked in one place and why that would or would not work in other places...” (Hospital 11, full participant).

As part of planning, the identification and engagement of internal champions was essential to adopting and launching the pathways. These champions often had pre-existing interest and expertise. As a chief medical officer stated, “You need staff, and we did - because we had a nurse champion that took this and ran with it. I could see other places that don’t have that champion that could have some struggles.” (Hospital 20, partial participant)

Program Design and Clarity

Non-participating hospitals cited difficulty understanding program requirements as a barrier to adopting pathways. Even partially and fully participating hospitals expressed challenges understanding program requirements when they were initially announced. Although most questions were resolved through communication with DHS, where HAP acted as key mediator, many hospitals expressed that the time between program announcement and participation deadline was not sufficient to prepare. Some hospitals appreciated that the open-ended program design allowed for adaptation to local circumstances, but some also stated that the lack of details or model pathways generated uncertainty: “I think it was open-ended purposefully, probably to allow some innovation and local implementation. But there were just some details that weren’t entirely clear to us” (Hospital 5, partial participant).

Technology and Data Collection

Nearly all hospital leaders described the need to employ technology to 1) implement HQIP pathways and 2) to collect data on effectiveness. Some hospitals used more advanced approaches to implement pathways through the electronic health record (EHR) and generate reports on patient outcomes. But most hospitals expressed difficulty in collecting accurate data on whether patients actually were able to obtain follow-up treatment. The main reason cited was that patients obtained follow-up care at community sites external to the health system, without interoperability. Some hospitals attempted to manually collect external data, as described by one director of toxicology: “When you refer somebody outside the system, there’s no great way of knowing if that individual engaged. It becomes an active process. In my county, I’m working to make phone calls - and educating my providers on how to do it, including social workers.” (Hospital 11, full participant).

Many hospital leaders expressed the desire to receive outcomes data from the state, noting that more frequent or even real-time feedback would be useful in implementation and sustainability of treatment pathways: “I’m kind of in the dark as to whether we’re meeting our goals or not. It would be nice if we could get some type of a quarterly feedback or report of, ‘you have these many patients,’ and ‘these many patients got their treatment.’ ” (Hospital 14, partial participant).

DISCUSSION

Financial incentives and other value-based approaches have the potential to drive swift system and practice changes needed to intervene in the opioid epidemic. Our study examined a voluntary financial incentive program in Pennsylvania to understand the reasons that hospitals accepted or declined participation. The themes that we identify reflect the willingness and ability of hospitals to enact evidence-based practices, as well as the many internal and external influences on implementing treatment pathways.

Other states have elected to follow other policy approaches to improving opioid follow-up treatment.²⁵ Massachusetts mandates that patients receive a specialized substance use evaluation within 24 hours of presenting for emergency care.²⁶ Rhode Island imposes stricter rules, requiring this evaluation prior to discharge from the ED, in addition to the use of evidence-based protocols for discharge planning and coordinating with outside providers.³⁷ Pennsylvania is unique in establishing a voluntary incentive program which specifies goals for hospitals but, by design, allows hospitals to adapt to local practice, resources, and environment.²⁸ The effectiveness of all of these strategies for improving patient outcomes has yet to be evaluated, which will require quantitative analysis of patient outcomes in relation to pathway implementation.

The HQIP program exclusively awarded funds to hospitals. However, hospitals required external community partners to receive patients in ongoing treatment. We found that implementation of pathways required robust outpatient services, which in Pennsylvania had been organized and supported through separate initiatives.^38,39 Larger hospitals and health systems maintained internal resources unavailable to small or independent facilities. In the absence of either internal or external resources, some hospitals were not able to participate in the program. Future programs may consider gain-sharing or dual support for referring and receiving facilities. In addition, different approaches may be needed for rural communities, including support for substance use treatment in primary care or telemedicine.^40,41

We found that few hospitals anticipated incentive payments in their operating budgets. The specific amount of payment may not have been as important as the prioritization of access to treatment - among competing priorities - that resulted from the link to funding. Hospitals were often on the cusp of change and responded to this nudge. Some hospital leaders expressed uncertainty as to whether they could successfully implement pathways but chose to participate nonetheless, given the absence of penalties. Yet the lack of risk was not enough to motivate all hospitals to participate. While some hospitals misunderstood program requirements and therefore declined to participate, others expressed a lack of readiness for change. Alternative or delayed inducements might be appropriate for hospitals in a different phase of readiness. Future studies may assess alternative approaches which were not explicitly addressed in this study, such as different incentive amounts and strategies that incorporate behavioral economic interventions (including loss aversion, relative social ranking, and goal gradients).⁴²

A common obstacle to full HQIP participation was the requirement to initiate buprenorphine in the ED. Barriers to administering and prescribing buprenorphine are well-described.^43–45 This medication requires a DEA “X” waiver to prescribe, and stigma likely influences willingness to offer it to patients. However, buprenorphine (as well as methadone maintenance therapy) has been consistently shown to be the most effective treatment modality for opioid use disorder.^46–49 This study supports previous findings by Hawk et al that implementing buprenorphine requires time-intensive training for physicians, in addition to concerns for nursing education, pharmacy availability, establishment of clear plans for ongoing care, and effects on patient throughput.⁴⁵ Full participants that did implement buprenorphine were able to prioritize this approach over competing needs, develop efficient pathways, arrange provider training, and ensure linkage to care. Partial participants, however, were only willing to connect patients with external providers capable of providing buprenorphine but not yet willing to change practices of their own providers. Given that evidence supports improved retention in treatment following ED initiation of buprenorphine rather than referral for initiation, incentives need to overcome the multifaceted barriers for this key treatment modality.¹⁴

Finally, challenges related to data collection affected both willingness to participate as well as implementation of treatment pathways. For other pay-for-performance initiatives, many hospitals monitor performance internally, using reports derived from the EHR. However, linkage of patients to treatment often required feedback from community partners without data-sharing infrastructure. Sharing of data for substance use treatment is also restricted under regulations for protected health information. Without active feedback, hospitals could not determine whether pathways were successful, make iterative changes, or use behavioral techniques such as report cards to further motivate providers.

This study had several limitations. First, the qualitative design of this study used semi-structured questions that were subject to response bias, given the status of interview participants as leaders of their respective organizations. Second, this study had the potential for selection bias in the people and organizations that elected to be interviewed, although we attempted to obtain a broad range of perspectives from different types of hospitals. A related limitation is that due to the small study sample size, we were unable to fully stratify the analysis by the full range of hospital characteristics, although an exploratory analysis considered key themes in relation to hospital participation status. Fourth, we interviewed stakeholders with varied roles within their organizations, generating diversity of perspective but potentially creating inconsistency. Finally, interviews were conducted in the three months immediately following the deadline to participate in process incentive. This timing was purposeful in that all hospitals had declared their participation but created the potential for recall bias.

CONCLUSION

The challenge of solving the opioid epidemic requires bold policymaking. Value-based payment models, including financial incentives, will become essential to overcoming knowledge-to-implementation gaps in best practices. Pennsylvania created the first financial incentive program to induce hospitals to facilitate linkage from hospital EDs to sustained outpatient care. Participation in this program and implementation of treatment pathways offer key lessons for future iterations of opioid-centered incentive programs. Future work is needed to determine the effectiveness in improving patient outcomes for not only the HQIP initiative but also emerging delivery models, regulatory changes, and payment innovations in the care of opioid use disorder.

Highlights.

• Pennsylvania created the first voluntary financial incentive program for hospitals to improve the rate at which patients with opioid use disorder receive follow-up treatment after emergency department care

• Qualitative interviews with hospital leaders were used to examine participation in the program and implementation of opioid treatment pathways

• The financial incentive induced system and practice changes at hospitals including partnership with community organizations, although many hospitals noted challenges in measuring performance and implementing buprenorphine prescribing