Policy and Payment Factors Influencing Adoption of Low-Barrier Buprenorphine Treatment

Importance: Treatment of opioid use disorder (OUD) with buprenorphine reduces overdose and all-cause mortality, yet access and retention remain limited. Much of the literature describing barriers to buprenorphine access and retention has focused on practitioner-level or patient-level barriers, but less is known about how potential policy and payment levers may influence prescribing behaviors and treatment practices from the practitioner perspective. Objective: To explore perspectives among OUD treatment program clinicians and staff about how broader policy and payment structures influence adoption of buprenorphine treatment and low-barrier care practices that promote access and retention. Design, Setting, and Participants: In this qualitative study, semistructured interviews were conducted from December 2022 to July 2023. Participants included clinicians and staff from a range of outpatient treatment programs providing buprenorphine in Philadelphia, Pennsylvania. Main Outcomes and Measures: Interviews examined prescribing practices and the influence of policy, payment structures, and regulatory requirements on clinical care. Transcripts were analyzed using thematic content analysis. Results: A total of 28 practitioners and staff (13 men [46%]; 11 [39%] aged 41-50 years), including medical clinicians, therapists, and other administrative staff, were interviewed. Participants included 17 physicians (61%), 7 therapists (25%), 1 advanced practice practitioner (4%), 1 administrator (4%), and 2 other staff (8%). Twenty-four participants (86%) had at least 5 years of experience treating OUD, and all clinicians had obtained a DATA-2000 waiver, also called an X-waiver, to prescribe buprenorphine. Participants viewed the X-waiver as a symbolic barrier, but identified policy factors like insurance coverage, reimbursement rates, payer policies, and licensure requirements as key variables influencing clinical practice. Clinics relied on supplemental funding to sustain care for uninsured patients. Participants reported that payer-imposed requirements, such as prior authorizations and rigid attendance-based reimbursement, undermined timely access and individualized care and that regulatory frameworks often conflicted with harm reduction principles and created staffing and documentation burdens. Conclusions and Relevance: This qualitative study of clinicians and staff in buprenorphine treatment programs found that broader policy and payment reforms could help support low-barrier buprenorphine treatment. Enhancing reimbursement, reducing administrative burdens, and aligning licensure and payer policies with evidence-based practices may improve access and retention. These findings offer actionable insights for policymakers, payers, and health systems seeking to address persistent gaps in OUD treatment.