Access to buprenorphine assessed by ‘secret shopper’ study

More than third of simulated patients who portrayed themselves as heroin users seeking treatment were unable to get an appointment with a buprenorphine prescriber, and access was even lower among those reporting Medicaid coverage.


Many buprenorphine prescribers did not offer new appointments or rapid buprenorphine access to simulated patients portraying active heroin use, particularly those callers who portrayed themselves as having Medicaid coverage compared to cash payments, a study found.

To assess real-world access to buprenorphine-naloxone treatment for uninsured or Medicaid-covered patients reporting current heroin use, researchers conducted a “secret shopper” study in areas with a high burden of opioid-related mortality: Massachusetts, Maryland, New Hampshire, West Virginia, Ohio, and Washington, D.C. From July to November 2018, callers contacted 546 publicly listed buprenorphine prescribers twice, posing as uninsured or Medicaid-covered patients seeking buprenorphine treatment, to assess rates of new appointments offered, whether buprenorphine prescription was possible at the first visit, and wait times. Results were published June 4 by Annals of Internal Medicine.

Among 1,092 contacts with 546 clinicians, schedulers were contacted in 849 calls (78% response rate). Clinicians offered new appointments to 54% of Medicaid contacts and 62% of uninsured or self-pay contacts, and 27% of Medicaid and 41% of uninsured or self-pay contacts were offered an appointment with the possibility of buprenorphine prescription at the first visit. The median wait time to the first appointment was 6 days (interquartile range [IQR], 2 to 10 days) for Medicaid contacts and 5 days (IQR, 1 to 9 days) for uninsured or self-pay contacts, the authors reported. These wait times were similar regardless of clinician type or payer status. The median wait time from first contact to possible buprenorphine induction was 8 days (IQR, 4 to 15 days) for Medicaid and 7 days (IQR, 3 to 14 days) for uninsured or self-pay contacts.

The authors noted that these wait times were not long, generally no worse than estimates for general primary care in other settings, implying that opportunities may exist to increase access by better use of existing prescribers. “On the clinician side, increasing reimbursement for services related to OUD [opioid use disorder] treatment and reducing administrative barriers to prescribing might encourage more providers to treat Medicaid enrollees,” the authors wrote.

An editorial stated that there was large variability among the studied locations in whether Medicaid or cash-only patients had access to more clinicians, despite all states having expanded Medicaid.

“For persons with OUD, timely access to treatment avoids harm from continued use of illicit opioids and may capitalize on a period of motivation for treatment,” the editorial stated. “Thus, a notable finding of this study was that among clinicians willing to provide an appointment, wait times were short—approximately 5 to 6 days—and almost half the providers offered same-day treatment initiation.”