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. Author manuscript; available in PMC: 2023 Jun 1.
Published in final edited form as: Health Aff (Millwood). 2022 Jun;41(6):901–910. doi: 10.1377/hlthaff.2021.01719

Medicaid Managed Care: Access to Primary Care Providers Who Prescribe Buprenorphine

Mark K Meiselbach 1, Coleman Drake 2, Brendan Saloner 3, Jane M Zhu 4, Bradley D Stein 5, Daniel E Polsky 6
PMCID: PMC9245197  NIHMSID: NIHMS1810074  PMID: 35666962

Abstract

Medicaid managed care (MMC) insurers play a crucial role in facilitating access to buprenorphine to treat opioid use disorder. Using a novel set of provider directory and prescription claims data, we examined variation in access to in-network buprenorphine-prescribing primary care providers (PCPs) in MMC. Approximately 32.2% of MMC enrollees had fewer than one in-network buprenorphine prescriber per 100,000 county residents. On average, there was a greater number of in-network buprenorphine-prescribing PCPs in states with higher as compared with lower overdose rates. However, most enrollees live in areas with a shortage of in-network buprenorphine-prescribing PCPs. We found that a 25% higher network participation rate by prescribers compared to non-prescribers could improve the probability that enrollees see a prescriber by approximately 25%. Policies to improve access within MMC include using PCP assignment algorithms to match patients with buprenorphine prescribers and requiring that networks include a minimum number of buprenorphine prescribers.

INTRODUCTION

The opioid crisis continues to be a major health policy priority in the United States, with nearly 70,000 opioid-related deaths in 2020, an increase of approximately 37% over 2019 (1). Buprenorphine is highly effective in treating opioid use disorder (OUD) and preventing overdoses (2–7). However, buprenorphine continues to be underutilized, as 70–80% of people with OUD do not receive any medication for OUD (8, 9).

A significant barrier to utilization is the small number of roughly 50,000 total physicians and advance practitioners who actively prescribe buprenorphine (10–12). Primary care providers (PCPs) play a particularly important role in providing access to buprenorphine, representing over 40% of all buprenorphine prescribers and over 60% of high-volume prescribers (12). PCPs, including primary care physicians, nurse practitioners, and physician assistants, have also driven recent increases in the uptake of buprenorphine for OUD (13). Furthermore, OUD is a chronic condition (14, 15), for which PCPs serve as the main source of care for many enrollees and the first line of contact for patients seeking help (16, 17). Compared to specialists, PCPs provide similar or better quality buprenorphine treatment (18). However, only a small percentage of PCPs overall are waivered to prescribe buprenorphine (19), and many do not view buprenorphine as an effective treatment for OUD (20), despite robust evidence to the contrary (2–7).

Medicaid plays a critical role in ensuring access to buprenorphine prescribers as it covers an estimated 40% of persons with OUD (21). The expansion of Medicaid following the Affordable Care Act has increased utilization of buprenorphine (22, 23), but gains have been limited by the local supply of buprenorphine prescribers (24). In forty states, Medicaid programs are managed through Medicaid managed care (MMC) insurers that are awarded state contracts and paid on a per-member-per-month basis to manage care for beneficiaries who enroll in their plans (25).

A key aspect of MMC is that insurers contract directly with a restricted network of providers who can accept patients enrolled in their plan. The management of networks within MMC, therefore, represents an important factor in determining enrollee access to buprenorphine prescribers. Typically, enrollees who do not select their own PCPs are automatically assigned to an in-network PCP who serves as a gatekeeper to other specialists (26). Enrollees are automatically assigned to PCPs by state algorithms that do not consider whether the enrollee has an OUD or if the provider prescribes buprenorphine (referred to as “automatic assignment” throughout).

Despite the potential importance of provider network design to access and utilization, prior work has not investigated networks for the presence of buprenorphine prescribers in MMC, due in part to data limitations. In this paper, we provide new evidence on how access to in-network buprenorphine-prescribing PCPs in MMC varied across networks, states, and counties, using a novel dataset linking MMC provider networks, buprenorphine prescribing patterns, and provider locations and specialties. Additionally, since the severity of the opioid crisis differs considerably across states (27), we assessed whether access to buprenorphine-prescribing PCPs within MMC varies by the rate of overdose deaths within a state. We then describe the likelihood that automatic assignment would match an enrollee with an in-network primary care physician who prescribes buprenorphine.

STUDY DATA AND METHODS

Data Sources

We created a novel dataset that overlays the availability of buprenorphine prescribing PCPs with detailed MMC network plan participation data, enabling the first analysis of network design for buprenorphine prescribing PCPs serving patients enrolled in MMC.

First, we used the Kaiser Family Foundation’s Medicaid Managed Care Market Tracker (28), derived from the Medicaid Managed Care Enrollment Report (29), to identify MMC plans serving adult beneficiaries. We excluded MMC plans specific to special needs, dual coverage, or child enrollees. We identified 232 eligible MMC plans across 37 states with over 10% penetration of MMC for the general adult population in the state. For each MMC plan, we included only counties within the plan’s service area based on enrollment totals from the Decision Resources Group (DRG) Interstudy Enrollment data (30). The DRG data contain county level enrollment for each insurer, collected through DRG’s National Proprietary Census, and have been used in prior work to capture enrollment and define service areas in MMC (31).

Second, we used the 2019–2020 Vericred Provider Networks data (32) to identify in-network providers for plans in our sample. Vericred is a private company offering researchers access to provider network data, collected by scraping insurer’s online plan provider directories. Vericred imposes internal quality assurance processes to ensure accurate information is provided to its commercial clients, working directly with insurance carriers to limit potential inaccuracies in the network directories. These data have been used in prior work on provider networks in managed care (31, 33, 34). We examined 174 of the eligible plans with robust provider network data in the Vericred database, covering 82.2% of total MMC enrollment. We primarily used 2019 Vericred Provider Networks data; however, for 10 plans in our sample that were added to the database in 2020, we used 2020 Vericred Provider Networks data.

Third, we used the IQVIA OneKey database of health care professionals (35) and linked to provider network lists by National Provider Identifier to identify the active in-network PCPs and their practice locations. The OneKey database integrates data from IMS Health, SK&A, and Healthcare Data Solutions to identify more than 10.7 million health care professionals in the US. Active OneKey providers were defined as those active in the National Plan and Provider Enumeration System who were born in 1940 or later, accept Medicare payments, and practice at an office, hospital, or residential facility. See Appendix Exhibit A1 for details on the inclusion and exclusion of PCPs (36). A subset of providers with primary care, nurse practitioner, or physician assistant specialties were included in the analysis, resulting in 224,616 eligible primary care physicians and 285,766 nurse practitioners and physician assistants.

Finally, among eligible PCPs identified in the OneKey database, we used IQVIA Real World Data-Longitudinal Prescriptions data to identify 11,587 primary care physicians (5.2% of eligible primary care physicians) and 6,531 nurse practitioners and physician assistants (2.3% of eligible nurse practitioners and physician assistants) with at least one prescription for a buprenorphine formulation indicated for the treatment of OUD filled at a retail pharmacy from January through December 2018. Buprenorphine prescriptions with formulations indicated for the treatment of pain were not used to identify prescribers. The IQVIA prescription data captures about 90% of all prescriptions filled at retail pharmacies in all 50 states and the District of Columbia. (37). The data are collected directly from retail pharmacies and coding centers and have been used in prior work to identify buprenorphine prescribers (12).

Measures and Analysis

We sought to characterize enrollee access to buprenorphine-prescribing PCPs within their MMC network and county; therefore, we set our unit of analysis at the level of a unique MMC network and county and weighted all analyses by the number of enrollees in that MMC network living in that county.

Our main measure of access was the number of in-network buprenorphine-prescribing PCPs—including primary care physicians, nurse practitioners, and physician assistants—in a MMC network per 100,000 county residents. The population of residents was measured using 2019 Census data (38). The access measure captured the supply of active buprenorphine prescribers available to Medicaid enrollees through different MMC networks and counties. We normalize this measure by total population, as opposed to the number of MMC enrollees, since prescribers that participate in MMC may also treat patients outside of MMC.

Our second measure of access to buprenorphine prescribers in MMC was the percentage of primary care physicians in an MMC network in a county who prescribe buprenorphine. A higher percentage of primary care physicians who prescribe buprenorphine could increase the chances that patients with OUD would be automatically assigned to a buprenorphine-prescribing clinician. In this measure, we focus on primary care physicians, who we define as active physicians in OneKey with a specialty of internal medicine, family medicine, or general medicine. Further, primary care physicians are most likely to be eligible for automatic assignment as PCPs across all MMC plans, as many MMC plans do not allow non-physicians to qualify as an enrollee’s assigned PCP (39, 40).

We summarized these two measures from the perspective of MMC beneficiaries and therefore weighted the measures by the number of enrollees in that network and county. We presented the distribution of these summary measures overall, by state, and by whether the county was in a state above or below the median overdose deaths per 100,000 (i.e., states with “high” vs. “low” overdose death rates). State overdose death rates were based on a 5-year average of state-level estimates of overdose deaths per 100,000 residents from 2015–2019 Centers for Disease Control and Prevention data (27).

Finally, we examined how a plan’s selection of provider networks might impact the probability of automatic assignment to a buprenorphine-prescribing primary care physician. We compared the percentage of primary care physicians within a network and county who prescribed buprenorphine to the percentage of PCPs who prescribed buprenorphine in that county overall. For this comparison, we calculated the enrollment-weighted mean, median, and interquartile range of these measures. The Johns Hopkins Institutional Review Board approved this study with a waiver of consent.

Limitations

This study is subject to limitations. First, there may be inaccuracies in the provider network directory data. In addition to Vericred’s quality assurance processes, we assessed individual networks to ensure no empty or implausibly small provider networks within the identified service areas for our included MMC plans. See Appendix Exhibit A2 for details on inclusion and exclusion criteria for MMC networks (36).

Second, we examined access to buprenorphine prescribers at the county level, recognizing that the size of the county and availability of transportation can often serve as barriers to access for individuals residing within a county. While access measures constructed at the county level describe the average enrollee’s experience (41), they may inaccurately describe a particular enrollee’s access (e.g., if they live at the border of a county).

Third, we were unable to distinguish whether network participation by buprenorphine-prescribing PCPs in MMC reflects selective contracting by insurers or provider preferences.

Fourth, we use state level overdose death rates to stratify high and low overdose areas; however, there is geographic variation in the need for buprenorphine prescribers within states. State level estimates were available for all 37 states included in our analysis, whereas estimates at a county level were only available in 13 states. In this subset of 13 states, we found that the number of in-network prescribers was higher in high overdose counties compared to low overdose counties, consistent with the findings described in this paper.

RESULTS

We found large variation in MMC enrollees’ access to buprenorphine-prescribing PCPs across states (Exhibit 1). Nearly one-third (32.2%) of MMC enrollees, roughly 17.4 million people, had less than one in-network buprenorphine-prescribing PCP in their county per 100,000 population, while 11.6% of enrollees (approximately 6.3 million enrollees) had more than five in-network buprenorphine-prescribing PCPs per 100,000 population in their county. See Appendix A3 for county level enrollment estimates (36). The average state had 3.2 in-network buprenorphine-prescribing PCPs per 100,000 population, with rates ranging from 0.4 in Florida and 0.6 in Texas to 11.8 in New Hampshire. See Appendix Exhibit A4 and A5 for separate maps of primary care physician prescribers and nurse practitioner and physician assistant prescribers, respectively (36).

Exhibit 1.

Exhibit 1

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State Variation in In-Network Buprenorphine-Prescribing Primary Care Providers per 100,000 Population, 2019

Source: 2019–2020 Vericred Provider Networks Data containing network identifiers and provider NPIs for Medicaid Managed Care plans, 2019 OneKey provider database containing provider characteristics including specialty and location, 2019 IQVIA prescription claims data containing buprenorphine prescription fills and prescribing provider NPIs, 2019 American Community Survey containing population estimates, 2019 Decision Resources Group InterStudy Enrollment data containing plan-county enrollment, 2015–2019 Centers for Disease Control and Prevention state overdose deaths.

Notes: Average in-network buprenorphine-prescribing providers per 100,000 population was calculated by taking the within-state enrollment-weighted average number of in-network buprenorphine-prescribing providers across all networks in the state and dividing by the state total population. States were then categorized into access categories based on the average. Buprenorphine-prescribing primary care providers included primary care physicians, nurse practitioners, and physician assistants with a prescription of buprenorphine to treat opioid use disorder. States in white were not included in the analytic sample.

In Exhibit 2, we describe enrollee access to in-network buprenorphine prescribing PCPs. We show the cumulative percentage of enrollees with fewer than a certain number of in-network prescribers per 100,000 population. We find that in high and low overdose states, 25% of enrollees have access to less than 0.7 and 0.6 in-network buprenorphine prescribers per 100,000 population, respectively. In high overdose states, however, there was a greater number of in-network prescribers for the remaining 75% of enrollees. In high overdose states, 50% of enrollees had access to 1.9 or greater prescribers per 100,000 population. In low overdose states, 50% of enrollees had access to 1.2 or greater prescribers per 100,000. For the 25% of enrollees with access to the greatest number of in-network prescribers, those in high overdose states had at least 3.9 in-network prescribers per 100,000 population, compared to 2.3 in low overdose states.

Exhibit 2.

Exhibit 2

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Medicaid Managed Care Enrollees’ Access to In-Network Buprenorphine-Prescribing Primary Care Providers in High and Low Overdose Death States, 2019

Source: 2019–2020 Vericred Provider Networks Data containing network identifiers and provider NPIs for Medicaid Managed Care plans, 2019 OneKey provider database containing provider characteristics including specialty and location, 2019 IQVIA prescription claims data containing buprenorphine prescription fills and prescribing provider NPIs, 2019 American Community Survey containing population estimates, 2019 Decision Resources Group InterStudy Enrollment data containing plan-county enrollment, 2015–2019 Centers for Disease Control and Prevention state overdose deaths.

Notes: Network-counties were divided into high and low overdose death states based on whether their state overdose rate was at or above the state median overdose deaths per 100,000 population. Within each stratification, we then calculated the number of in-network buprenorphine-prescribing primary care providers per 100,000 population. The percentage of enrollees at each level of access was calculated and cumulative percentages are displayed. Buprenorphine-prescribing primary care providers included primary care physicians, nurse practitioners, and physician assistants with a prescription of buprenorphine to treat opioid use disorder.

We also found substantial variation in the percentage of in-network primary care physicians who prescribed buprenorphine across states (Exhibit 3). Overall, 49.5% of enrollees were enrolled in networks with 5% or less of primary care physicians who prescribed buprenorphine, while 28.1% of enrollees had networks with greater than 10%. The state average percentage of in-network primary care physicians was 6.9%. The percentage of prescribers ranged from the lowest levels in Iowa with 1.5% and Nebraska with 2.1% to the highest levels in New Mexico with 17.0% and Oregon with 16.9%.

Exhibit 3.

Exhibit 3

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State Variation in Percentage of In-Network Primary Care Physicians who Prescribe Buprenorphine, 2019

Source: 2019–2020 Vericred Provider Networks Data containing network identifiers and provider NPIs for Medicaid Managed Care plans, 2019 OneKey provider database containing provider characteristics including specialty and location, 2019 IQVIA prescription claims data containing buprenorphine prescription fills and prescribing provider NPIs, 2019 Decision Resources Group InterStudy Enrollment data containing plan-county enrollment, 2015–2019 Centers for Disease Control and Prevention state overdose deaths.

Notes: The percentage of in-network primary care physicians who prescribed buprenorphine was calculated by taking the within-state enrollment-weighted percentage of in-network primary care physicians who prescribed buprenorphine across all networks in the state. States were then categorized into access categories based on this measure. Buprenorphine-prescribing primary care physicians included those with a prescription of buprenorphine to treat opioid use disorder. States in white were not included in the analytic sample.

The comparison between high and low overdose states using the measure of access based on the percentage of in-network primary care physicians that prescribe buprenorphine (Exhibit 4) revealed similar patterns to Exhibit 2. The median percentage of in-network PCPs prescribing buprenorphine was 5.2% in high overdose states and 5.0% in low overdose deaths states. However, access was better in high overdose states for enrollees at the 75th percentile (8.3%) compared to enrollees in low overdose states (7.4%).

Exhibit 4.

Exhibit 4

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Percentage of In-Network Primary Care Physicians who Prescribe Buprenorphine for Medicaid Managed Care Enrollees in High and Low Overdose Death States, 2019

Source: 2019–2020 Vericred Provider Networks Data containing network identifiers and provider NPIs for Medicaid Managed Care plans, 2019 OneKey provider database containing provider characteristics including specialty and location, 2019 IQVIA prescription claims data containing buprenorphine prescription fills and prescribing provider NPIs, 2019 Decision Resources Group InterStudy Enrollment data containing plan-county enrollment, 2015–2019 Centers for Disease Control and Prevention state overdose deaths.

Notes: Network-counties were divided into high and low overdose death states based on whether their state overdose rate was at or above the state median overdose deaths per 100,000 population. Within each stratification, we calculated the percentage of in-network primary care physicians who prescribed buprenorphine. The percentage of enrollees at each level of access within either stratification was calculated and the cumulative percentages are shown. Buprenorphine-prescribing primary care physicians included those with a prescription of buprenorphine to treat opioid use disorder.

We further compared the percentage of in-network primary care physicians who prescribe buprenorphine to the percentage of all primary care physicians in a county who prescribe, regardless of network participation. For the average MMC enrollee, only 5.2% of PCPs in their county prescribed buprenorphine; however, 6.6% of PCPs included in their MMC network in their county prescribed buprenorphine. See Appendix A6 for graphical representation of these data (36).

In other words, the probability that an in-network PCP in an enrollee’s county prescribed buprenorphine was approximately 25% higher than the probability that any PCP in their county overall prescribed buprenorphine. For the median enrollee, the percentage of PCPs in their county who prescribed buprenorphine was 3.9% (25th/75th percentile = 2.8%/6.1%) compared to 5.1% (25th/75th percentile = 2.6%/7.8%) within their MMC network and county.

DISCUSSION

This study is the first to measure access to in-network buprenorphine prescribers in MMC, the most common form of health insurance for persons with OUD. We find that 50% of enrollees in states with high overdose rates had access to less than 1.3 buprenorphine prescribers per 100,000 population; in low overdose states, 50% of enrollees had less than 1.0 prescriber per 100,000. When we adjust the definition of a Health Professional Shortage Area (HPSA) for PCPs provided by the Health Resources and Services Administration by the prevalence of opioid use disorder, our findings indicate that more than half of MMC enrollees live in areas with a shortage of buprenorphine prescribers in high and low overdose states. In comparison, roughly a quarter of the total population lives in an area designated as a primary care HPSA (42, 43).

We found evidence that MMC networks could play an important role in improving access to buprenorphine prescribers by targeting them for participation in their networks. A 25% higher rate of participation in MMC networks among buprenorphine prescribers increases the probability that an individual would be assigned to a buprenorphine-prescribing PCP by approximately 25%. However, even within MMC networks, the probability of automatic assignment to a buprenorphine-prescribing PCP is approximately 6.6%, highlighting that most individuals with OUD will not be automatically assigned to a prescriber.

Collectively, our findings highlight how MMC provider networks can be managed to improve access to buprenorphine prescribers by focusing on including these providers in MMC networks. This strategy could improve access to an in-network prescriber overall and also increase the likelihood that Medicaid enrollees get matched with a PCP who prescribes buprenorphine. This is important as the PCP to whom a beneficiary is automatically assigned may have a substantial influence on the treatments they receive (44, 45).

Our findings have several important policy implications. States with high overdose rates could implement a number of policies to increase access to buprenorphine-prescribing PCPs for residents with an opioid addiction. For example, states may increase Medicaid reimbursement for office-based buprenorphine treatment or issue clinical guidance to encourage buprenorphine use (10). Additionally, MMC networks may target buprenorphine-prescribers in these states for inclusion in their networks to meet the clinical needs of their patient population. Future work should seek to disentangle the relative contributions of policy and insurer decision-making.

For counties with the lowest levels of access across all states, there are policies that could expand access to buprenorphine prescribers within MMC. In addition to broad-based strategies that could increase the supply of prescribers overall, such as eliminating the X waiver for prescribing buprenorphine, more targeted strategies may be used to expand access. Expanding telehealth access within MMC networks while maintaining expansions of telehealth that occurred during the COVID-19 pandemic could help enrollees in underserved areas receive treatment from buprenorphine prescribers (46). Network adequacy regulations could also be used to ensure that all MMC networks include a minimum number of buprenorphine prescribers.

Finally, although we found that MMC enrollees have a greater probability than non-enrollees of seeing PCPs who prescribe buprenorphine, that probability remains low. Medicaid policymakers could assign enrollees with OUD to buprenorphine-prescribing PCPs rather than continuing the current practice of automatically assigning enrollees without regard to opioid use.

CONCLUSION

Access to buprenorphine-prescribing primary care physicians in Medicaid managed care constitutes a significant barrier to opioid agonist treatment for Medicaid enrollees with OUD. Despite higher potential need for buprenorphine, many enrollees in states with high overdose death rates have similarly low levels of access to those in states with lower overdose death rates. While a higher concentration of providers in MMC networks prescribe buprenorphine compared to providers who do not participate in MMC networks, the majority of enrollees live in counties with a small supply of prescribers who are unable to meet the demand for treatment. Alongside implementing policies to increase the supply of buprenorphine prescribers, policymakers should leverage MMC networks to expose enrollees with OUD to PCPs who prescribe buprenorphine.

Supplementary Material

appendix

Contributor Information

Mark K. Meiselbach, Department of Health Policy and Management, Johns Hopkins University Bloomberg School of Public Health, Baltimore, MD

Coleman Drake, Department of Health Policy and Management, University of Pittsburgh School of Public Health, Pittsburgh, PA.

Brendan Saloner, Department of Health Policy and Management, Johns Hopkins University Bloomberg School of Public Health, Baltimore, MD.

Jane M. Zhu, Oregon Health and Science University, Portland, OR

Bradley D. Stein, RAND Corporation, Pittsburgh, PA

Daniel E. Polsky, Department of Health Policy and Management, Johns Hopkins University Bloomberg School of Public Health, Baltimore, MD

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Supplementary Materials

appendix
NIHMS1810074-supplement-appendix.docx (710KB, docx)

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