Estimated Hospital Cost Reduction Following Implementation of Hospital-dispensed Discharge Methadone

Abstract

Objectives:

US regulatory changes now allow practitioners to dispense up to a 3-day supply of methadone from the inpatient pharmacy at hospital dishcarge at one time. We characterized outcomes related to hospital-dispensed discharge methadone, including saved hospital days and reductions in hospital costs.

Methods:

We included all hospitalizations involving hospital-dispensed discharge methadone for opioid use disorder. We identified the mean number of discharge methadone doses ordered per hospitalization to determine a reduction in length of hospital stay, where 1 discharge methadone dose equals 1 hospital day saved. We used 2 approaches: a health care cost accounting approach that uses patient-level health care cost data and an adjusted inpatient day metric that uses data from the hospital’s aggregated operating costs to estimate hospital cost reductions related to discharge methadone.

Results:

Between April 2023 and July 2025, 175 hospitalizations involving 374 orders for discharge methadone reduced length of stay by 357 days after accounting for split doses, that is, twice daily doses for pain, pregnancy, or rapid methadone metabolism. The mean number of discharge methadone doses per hospitalization was 2.1. Using a health care cost accounting approach, the median cost reduction was $850/d with a total cost reduction of $304,450 over the study period. Using an adjusted inpatient day estimate, the total cost reduction was $3953/d with a total cost reduction of $1,411,221 over the study period.

Conclusions:

Hospital-dispensed discharge methadone reduced costs by facilitating hospital discharges. Cost savings related to reduced emergency department overcrowding or avoidance of nosocomial infections were not captured and should be considered when implementing discharge methadone processes.

In 2023, the US government amended federal regulations allowing practitioners to dispense up to a 3-day supply of methadone for opioid withdrawal at one time.^1,2 In response, hospitals implemented federally compliant processes to dispense methadone from the inpatient pharmacy for patients with opioid use disorder (OUD) to facilitate hospital-to-opioid treatment program (OTP) linkage.^3–5

Medically stable patients on methadone for OUD are often housed in the hospital over weekends and holidays when OTPs are closed to ensure methadone treatment continuation to avoid opioid withdrawal and return to unprescribed opioid use.⁶ Providing hospitalized patients with “bridge” methadone doses supports hospital-to-subacute care transitions, ensures travel time between the hospital to OTP, and likely facilitates OTP linkage during usual business hours while shortening hospital length of stay (LOS).

This study characterizes outcomes related to the provision of hospital-dispensed discharge methadone, including hospital days saved due to shortened LOS and hospital cost reductions.

METHODS

Study Design, Setting, and Population

This retrospective study occurred in a not-for-profit, university-affiliated, 775-bed hospital with an addiction consultation service in Colorado. Hospitalizations involved patients with moderate to severe OUD who received hospital-dispensed discharge methadone. The Colorado Multiple Institutional Review Board approved this study.

Outcomes

Study outcomes included (1) the mean number of discharge methadone doses ordered per hospitalization and (2) the estimated hospital cost reduction using (a) a health care cost accounting approach and (b) an adjusted inpatient day metric.

Data Sources

We queried health records from hospitalizations involving hospital-dispensed discharge methadone to identify the number of doses ordered, milligrams per dose, and the discharge day.

We used EPSi (Enterprise Performance Systems Inc.)⁷ to estimate hospital cost reductions using a health care cost accounting approach. EPSi is a cost accounting and decision support system used by health care organizations to manage financial performance. Hospitalizations involving discharge methadone were identified, and health care costs allocated to each patient’s account were obtained. Cost allocations included direct costs associated with clinical care provided during the hospitalization, including hospital staff labor costs, for example, salary/benefits of non-physician staff, physicians, and advanced practice professionals, billable and nonbillable health care supply costs, drug costs, and other costs (Fig. 1).

FIGURE 1.

Example of encounter costing and reimbursement considered in a health care cost accounting approach.

We used the Kaiser Family Foundation (KFF) adjusted inpatient day estimate⁸ to determine potential hospital cost reductions related to hospital-dispensed discharge methadone. KFF calculates the adjusted inpatient day metric by using data available in the American Hospital Association (AHA) Annual Survey.^9,10 The metric reports on hospital-wide averages and is calculated by dividing a hospital’s total operating costs (both inpatient and outpatient services) by the number of adjusted inpatient days, a standardized measure that accounts for the volume of outpatient services provided.⁸ AHA data allow for the comparison of average hospital costs per adjusted inpatient day across hospitals, states, and over time.⁸ In contrast to the health care cost accounting approach, the adjusted inpatient day approach does not involve patient-level data, but involves hospital-level data. In 2023, KFF estimated the adjusted inpatient day estimate for Colorado nonprofit hospitals to be $3953 per day.⁸

Analysis

Discharge Methadone Doses as Saved Hospital Days

To calculate saved days, we identified that the mean number of hospital-dispensed discharge methadone doses per hospitalization was 2.1 doses, representing 2 saved hospital days. Methadone for OUD is typically dosed once daily, but split doses are indicated for pain, pregnancy, or rapid methadone metabolism.¹¹ For patients dosing daily, we assumed that 1 discharge methadone dose was equivalent to 1 hospital day saved. We accounted for split methadone dosing by counting 2 split doses as a 1-day methadone supply.

Health Care Cost Accounting

To calculate the estimated cost reduction related to discharge methadone using the health care cost accounting approach, we averaged the total cost per hospital day for the last 2 days of hospitalization. To determine the total hospital cost reduction, we multiplied the median cost per day for the last 2 days of hospitalization by the total number of discharge methadone doses over the study period.

Adjusted Inpatient Day Metric

To calculate the estimated hospital cost reduction using the adjusted inpatient day metric, we multiplied $3953 by the total number of discharge methadone doses over the study period.

RESULTS

Between April 1, 2023, and July 7, 2025, 145 patients had 175 hospitalizations involving 374 hospital-dispensed discharge methadone doses. Of these, 34 hospitalizations involved split doses, equivalent to 17 daily hospital-dispensed discharge doses. The overall reduction in LOS over the study period was 357 days. The mean number of hospital dispensed discharge doses per hospitalization was 2.1, the mean methadone dose per dispensed order was 73.4 mg, and the most frequently listed days of hospital discharge were Friday (n = 62) and Saturday (n = 59) (Table 1).

TABLE 1.

Characteristics Involving Hospitalizations With Hospital-dispensed Discharge Methadone

Total number of patients, n	145
Total number of hospitalizations, n	175
Total number of methadone doses ordered, n	374
Total number of split methadone orders, n*	34
Mean number of methadone doses ordered per hospitalization, n	2.1
Mean methadone dose dispensed per order, mg	73.4
Total number of hospital days saved over the study period, n	357
Number of orders by discharge day of the week, n
Monday	13
Tuesday	9
Wednesday	13
Thursday	15
Friday	62
Saturday	59
Sunday	15

^*Split dose = total daily methadone dose is divided into 2 doses per day.

Using the health care cost accounting approach, the median cost of the final 2 hospital days was $850/d, resulting in a cost reduction of $303,450 ($850 ×357 doses) over the study period. Using the adjusted inpatient day estimate, the cost reduction was $1,411,221 ($3953 ×357 doses) over the study period.

DISCUSSION

In this analysis of hospital-dispensed discharge methadone, we quantified cost reduction from hospital days saved using 2 approaches: a health care cost accounting approach and the adjusted inpatient day estimate. These results may be used to build support for implementing and disseminating similar processes across US hospitals.

The hospital cost reductions were markedly different between the 2 approaches and may be attributed to 2 factors. The health care cost accounting approach includes encounter-level data specific to care provided to patients during hospitalizations involving discharge methadone. The adjusted hospital day estimate includes hospital-level, aggregated data and may overestimate the hospital costs of hospitalizations involving discharge methadone.

Next, differences in cost estimates reflect how we calculated hospital costs. In the health care cost accounting approach, we limited the data inputs to the last 2 days of hospitalization, informed by the mean number of hospital-dispensed discharge methadone doses per hospitalization. The latter days of hospitalization tend to incur fewer costs compared with the initial days of hospitalization when patients are more likely to be medically unstable. A previous report identified that ~40% of the variable hospital costs are incurred during the first 3 days of hospitalization.¹² In contrast, the adjusted inpatient day estimate uses aggregated, hospital-level data, which does not account for individual patient characteristics, diagnoses, procedures, or service lines and may overestimate hospital cost reductions associated with hospital-dispensed discharge methadone.

Finally, these approaches do not account for other unmeasured savings, that is, reduced emergency department crowding, reduced risk of nosocomial infections, and the potential to provide (and bill for) higher acuity interventions and services with greater patient throughput.^13–15

Limitations

The number of methadone doses ordered may vary from doses dispensed; that is, patients with a self-directed discharge may leave before methadone is dispensed, and the estimation that 1 methadone dose equals 1 hospital day may overestimate hospital days saved. There are limitations with each cost savings calculation. ESPi is proprietary and implemented differently across institutions, which may lead to variations in how costs are allocated and categorized, limiting generalizability across hospitals. AHA survey data, used in the KFF estimate, rely on self-reported data subject to reporting bias. The adjusted inpatient day metric reflects reported costs and does not account for variation in accounting practices or capital costs across hospitals.

CONCLUSIONS

In this study, hospital-dispensed discharge methadone doses reduced hospital costs by facilitating hospital discharges when OTPs are closed. Unmeasured cost savings related to greater patient throughput and reduced nosocomial infections were not captured and should be considered when implementing processes for discharge methadone.