Expanding Access to Methadone Treatment for Opioid Use Disorder: Measurement and Policy Considerations for the Veterans Health Administration

OBJECTIVE: To establish methods for comparing Department of Veterans Affairs (VA)-direct and VA-purchased "community care" (CC) for methadone medication for opioid use disorder (M-MOUD), and determine differences in access, quality, and cost. STUDY SETTING AND DESIGN: Three outcome measures were constructed: wait times (from clinician referral to appointment) for access, retention on M-MOUD (number of months, from one to six) for quality, and 6-month treatment costs (M-MOUD and related services). We used generalized linear models to estimate differences in each outcome for CC versus VA. DATA SOURCES AND ANALYTIC SAMPLE: VA electronic health record and CC claims. Our study included VA patients referred by clinicians for M-MOUD between April 1, 2023-March 31, 2024 in VA (n = 389) and CC (n = 219) and, secondarily, VA walk-ins (n = 1830). PRINCIPAL FINDINGS: Average unadjusted wait times from clinician referral to appointment were 15.73 days (standard deviation [SD] = 16.27) in VA and 19.03 days (SD = 19.12) in CC, while there was no wait time for Veterans seen as VA walk-ins. Average unadjusted M-MOUD retention was 2.07 months (SD = 1.65) in VA and 3.13 months (SD = 1.84) in CC. Average unadjusted 6-month costs were $7360 (SD = $9554) in VA and $4376 (SD = $2171) in CC. In adjusted models, CC had greater M-MOUD retention (1.07 months longer, p < 0.0001) and lower costs ($-1720, p < 0.05) compared to VA clinician referral; wait times did not statistically differ (p = 0.12). M-MOUD retention and cost patterns did not change when considering VA walk-ins. CONCLUSIONS: An important option for expanding Veterans' access to M-MOUD is through CC. In this group of Veterans receiving M-MOUD, CC retention was greater and costs were lower. However, CC lacks the walk-in option for same-day access. This signals tradeoffs to consider when assessing the balance between VA and CC and provides methods for comparing VA and CC treatment options.