A State Financial Incentive Policy to Improve Emergency Department Treatment for Opioid Use Disorder: A Qualitative Study

Objective:In 2019, Pennsylvania established a voluntary financial incentive program designed to increase the engagement in addiction treatment for Medicaid patients with opioid use disorder after emergency department (ED) encounters. In this qualitative study involving hospital leaders, the authors examined decisions leading to participation in this program as well as barriers and facilitators that influenced its implementation.Methods:Twenty semistructured 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. An iterative approach was used to analyze the interviews and determine key themes and patterns regarding implementation of this policy initiative in hospitals.Results:The authors identified six key themes that reflected barriers and facilitators to hospital participation in the program. Participation in the program was facilitated by community partners capable of arranging outpatient treatment for opioid use disorder, incentive payments focusing hospital leadership on opioid treatment pathways, multidisciplinary planning, and flexibility in adapting pathways for local needs. Barriers to program participation concerned the implementation of buprenorphine prescribing and the measurement of treatment outcomes.Conclusions:A financial incentive policy encouraged hospitals to enact rapid system and practice changes to support treatment for opioid use disorder, although challenges remained in implementing evidence-based treatment—specifically, initiation of buprenorphine—for patients visiting the ED. Analysis of treatment outcomes is needed to further evaluate this policy initiative, but new delivery and payment models may improve systems to treat patients who have an opioid use disorder.