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Building Comprehensive Responses to the Opioid Crisis

Allie Hunter, cofounder and president of Addiction Response Resources, in Roxbury, Mass., on Sept. 14, 2021. Funds from opioid settlements can be used to support various strategies for addressing opioid use disorder, including efforts for prevention; programs that distribute naloxone, clean syringes, and other harm-reduction tools; and recovery programs. Photo: Jessica Rinaldi/Boston Globe via Getty Images

Allie Hunter, cofounder and president of Addiction Response Resources, in Roxbury, Mass., on Sept. 14, 2021. Funds from opioid settlements can be used to support various strategies for addressing opioid use disorder, including efforts for prevention; programs that distribute naloxone, clean syringes, and other harm-reduction tools; and recovery programs. Photo: Jessica Rinaldi/Boston Globe via Getty Images

Allie Hunter, cofounder and president of Addiction Response Resources, in Roxbury, Mass., on Sept. 14, 2021. Funds from opioid settlements can be used to support various strategies for addressing opioid use disorder, including efforts for prevention; programs that distribute naloxone, clean syringes, and other harm-reduction tools; and recovery programs. Photo: Jessica Rinaldi/Boston Globe via Getty Images

  • Legal settlements with drug manufacturers and others accused of fueling the opioid crisis may lead to more comprehensive strategies for addressing opioid use disorder across the U.S.

  • From building “non-arrest” pathways to drug treatment and recovery to investing in recovery supports such as transitional housing, states and counties across the U.S. are testing new ways of responding to the opioid crisis

  • Legal settlements with drug manufacturers and others accused of fueling the opioid crisis may lead to more comprehensive strategies for addressing opioid use disorder across the U.S.

  • From building “non-arrest” pathways to drug treatment and recovery to investing in recovery supports such as transitional housing, states and counties across the U.S. are testing new ways of responding to the opioid crisis

In Raising Lazarus, Beth Macy’s latest book chronicling the opioid crisis, Macy describes how a North Carolina program that brings clean syringes and overdose-reversal medication to people who use drugs made inroads in some counties but struggled to gain footing in another, where leaders were focused on building a bigger jail.

Similar situations are playing out across the U.S., where local governments and different states have been trying an array of strategies to address opioid use disorder (OUD) and the broader drug overdose crisis. Some promote on-demand treatment or lean toward harm reduction, an approach that seeks to minimize the risks of drug use by distributing supplies like fentanyl test strips and naloxone, the overdose reversal drug, while others focus more on policing illicit drug activity. This inconsistency means that a person’s likelihood of gaining access to lifesaving OUD treatment and other supports is determined less by need and more by geography, cultural norms, and the role of state Medicaid programs, which are the single largest payer for OUD treatment.

The legal settlements now underway with opioid manufacturers, distributors, and pharmacies accused of fueling the opioid crisis offer funding to build more comprehensive approaches. While states’ attorneys general oversee the settlements, much of the money will be paid out to county governments, which can direct them toward an approved list of prevention, treatment, and recovery strategies. “No two counties are alike,” says Samantha Karon, senior program manager for substance use disorder at the National Association of Counties. “If a county already has a robust treatment system, perhaps settlement funds provide an opportunity to invest in prevention. Conversely, a county with a strong prevention system may use settlement funds to increase access to treatment, such as through a mobile treatment program or transportation services.”

In this issue of Transforming Care, we describe promising approaches in regions of the country that have made some headway in reducing drug overdoses and engaging people in treatment. Many of the programs are homegrown, launched with grant funds and the involvement of people who have lost loved ones or struggled to find support themselves. They demonstrate the value of creating multiple points of entry to treatment, and the need to offer social and financial supports to help people sustain their recovery. Other programs are led by states, which can leverage Medicaid programs and data to direct resources where they are most needed.

Putting the Opioid Settlement Funds to Work

Thousands of cities, counties, and states have sued drug manufacturers, distributors, and pharmacies for what they see as their roles in fueling the opioid crisis. Some of the lawsuits are still active while others have been settled.

Funds from the biggest settlement to date ($26 billion over 18 years) began being paid out in 2022. To avoid what happened with the 1998 tobacco settlement — in which less than 3 percent of funds were used to support smoking prevention or cessation — the agreement mandates that at least 70 percent of the funds must be directed toward abating the opioid crisis.

The funds can be used to support any of an approved list of strategies, including:

  • efforts to prevent OUD
  • programs that distribute naloxone, clean syringes, and other harm-reduction tools
  • programs that expand access to medications for OUD
  • efforts to strengthen treatment programs in prisons
  • efforts targeting people with OUD who are pregnant or postpartum
  • recovery programs.

Engaging People with OUD

Most people struggling with opioid use disorder aren’t identified and, even if they are diagnosed, many don’t receive treatment. In a survey from 2020, only 11 percent of those who were diagnosed with OUD received buprenorphine, methadone, or other medications for OUD (MOUD), the gold standard of treatment.

In some regions, leaders have found creative ways to identify and engage people who are struggling with substance use.

Plymouth County’s Hub Program

In 2021, drug overdose deaths surged past 100,000 in the U.S., a record high driven by exposure to synthetic opioids such as fentanyl, which is at least 50 times more potent than heroin. That year, the tally in Plymouth County, in Massachusetts just south of Boston, fell by 18 percent. Though data are still incomplete, the county was on track to reduce overdose deaths by another 20 percent in 2022.

Leaders there credit their success in part to the efforts of local police departments to build “non-arrest” pathways to drug treatment and recovery. Unlike drug courts that seek to divert people from the criminal justice system into treatment, the goal of these programs is to “deflect”— to reach people before they overdose or commit a drug-related crime.

To do so, in 2020 Plymouth County established four community hubs, where law enforcement officers and court officials meet regularly with the staff of hospitals, behavioral health agencies, schools, religious organizations, shelters, food banks, and other community organizations. Hub participants identify individuals in the community whom they deem to be at high risk for some type of harm, whether because of their substance use, mental health problems, pending eviction, acute hunger, or other issues.

The hub meetings are designed for real-time problem solving using a process that strives for anonymity: no records are kept and a limited amount of confidential information is shared only when it is determined that the person is at imminent risk. More often, participants discuss their concerns in general terms and suggest strategies and resources that may help. Staff from the organizations that are best positioned to help then meet separately to develop a plan. Typically, at-risk individuals will receive a visit and offer of support within 24 to 48 hours.

The hubs are grant-funded and managed by the Police Assisted Addiction & Recovery Initiative (PAARI), a nonprofit that provides coaching on deflection models to police departments nationwide. Before launching the hubs, Plymouth County had a program in which a plain-clothes officer and a peer recovery coach visited people after drug overdoses to offer naloxone. “That helped prevent future overdoses,” says Charlette Tarsi, M.Ed., a former drug and alcohol counselor who manages Plymouth County’s hubs for PAARI. “But what it wasn’t doing was helping the person with housing, poverty, mental health, physical ailments. Those were things that were continuing to cause stress in the person’s life and what was usually leading to substance use in the first place.”

Tarsi says the number of people discussed at the hubs has declined over time as participants have learned better approaches to engaging people. Her informal surveys of hub participants suggest that 70 percent of their clients accept referrals for services, including drug treatment.

Stanly County’s Post-Overdose Response Teams

Stanly County, in central North Carolina, also struggled with high numbers of opioid overdoses — among the highest in the state — before it implemented an outreach program in which community paramedics offer MOUD to people who have either been revived from overdoses with naloxone or are suffering other problems related to their substance use, such as withdrawal. The county’s EMS data showed that more than 60 percent of patients who’d experienced an overdose refused ambulance transfers to hospitals, often because of the stigma they’ve encountered from first responders as well as hospital staff.

In 2019, the county used grant funding to establish post-overdose response teams (PORTs), which pair community paramedics with certified peer support specialists. The teams respond to overdose calls day or night, following protocols established by the agency medical director. If indicated, paramedics can start giving buprenorphine — which quells opioid cravings by occupying opioid receptors in the brain — to people who have overdosed. They follow them for up to seven days, during which they try to connect them with ongoing MOUD treatment. 

The teams also link patients with supports such as shelters or rides to medical appointments. “We flood them with information, resources, and most important, kindness and some empathy,” says Mike Campbell, deputy EMS chief and community paramedic division supervisor.

In the last three years, PORT teams have given between 35 and 40 people initial doses of buprenorphine and have performed medical clearance tests to start MOUD for 50 more. Campbell credits the program with reducing overdose calls to EMS from more than 50 per month in 2020 to a high of six or seven a month now. For those not ready to engage in treatment, the team offers naloxone to reverse overdoses, as well as bag valve masks that people can use to maintain air flow to someone who has overdosed.

We flood them with information, resources, and most important, kindness and some empathy.

Mike Campbell Deputy EMS chief and community paramedic division supervisor, Stanly County

Eleanor Health

A startup company, Eleanor Health, is using medical claims data to proactively identify people who may be struggling with substance use. The company was launched in 2019 by Corbin Petro, previously the chief operating officer of Massachusetts’ Medicaid program, and Nzinga Harrison, M.D., a psychiatrist specializing in addiction medicine, who teamed up to build a new model of care for people with mental health problems and substance use disorders. It’s now partnering with Medicaid managed care companies and commercial insurers in seven states.

Through a combination of virtual and in-person staff, Eleanor Health offers same- or next-day access to a wide variety of services, ranging from detox and treatment — including MOUD and appointments with psychiatrists and licensed clinical social workers — to recovery supports. Between 30 percent and 40 percent of the roughly 50,000 people it serves are covered by Medicaid. Sixty percent have OUD.

“We're not calling folks and saying, ‘Hey, we see you’ve had six months of an opioid prescription, and we're here to help you.’ That does not open doors,” says Danica Patterson, Eleanor’s chief of markets. “We're reaching out to say, ‘We want to follow up and get you connected into care.’”

The first point of contact is a health coach, typically a community health worker, who elicits the member’s priorities. If someone says they’re concerned about their substance use, Eleanor Health assigns them a peer coach who explains what treatment might look like and emphasizes that they’ll never be “fired” for not agreeing to pursue it. 

The company receives per member per month fees for the outreach efforts and, depending on the contract, receives capitation or fee-for-service payments for medical services. It also shares in the savings that result from managing mental health and substance use issues, two major drivers of overall health care spending.

Patterson says the company has a 64 percent retention rate among people seeking help with substance use disorders, and that three-quarters of clients have improved measures of anxiety or depression. The company has tracked a 40 percent reduction in the number of ED visits and inpatient days among patients Eleanor’s staff have engaged over a 360-day period.

Lowering Barriers to Treatment and Reducing Harms

After people with OUD are identified, there are still challenges to connecting and retaining them in treatment. Evidence indicates that people who receive MOUD for a year or longer have better outcomes than those treated for shorter periods. There are number of impediments to making treatment more accessible in traditional health care settings, among them is the lack of providers trained and willing to care for patients with substance use disorders. The newly passed Mainstreaming Addiction Treatment Act — which removes the requirement for providers to obtain a waiver to prescribe buprenorphine — could encourage more providers to offer OUD treatment.

Pennsylvania’s Opioid Use Disorder Centers of Excellence Program

In 2016, Pennsylvania’s Governor Tom Wolf sought to respond to the state’s high drug overdose rate by introducing Opioid Use Disorder Centers of Excellence. Through this program, a range of providers — health systems, independent primary care practices, federally qualified health centers (FQHCs), and case management agencies — each received $500,000 in grant funding to establish comprehensive OUD treatment programs. The goal was to make treatment much more widely available, and to offer MOUD alongside counseling and social supports.

The initial funding enabled 45 organizations to create care management teams, made up of physicians, case managers, social workers, therapists, and peer recovery workers, to help people with OUD meet their physical and behavioral health needs and link them to housing, employment, transportation, and other social supports. To sustain the program, the state now requires Medicaid managed care plans to pay each center of excellence $277.22 per month for each member who receives wraparound supports; there are now nearly 250 centers of excellence around the state.


Scott Constantini, associate vice president of primary care and recovery supports integration, Wright Center for Community Health

The Wright Center for Community Health, a lookalike FQHC serving northeast Pennsylvania, including several rural counties, joined the program in 2017 after its CEO, a physician, lost one of her patients to an opioid overdose. Since becoming a Center of Excellence, the Wright Center has trained more than 30 providers to prescribe MOUD and has four who are board-certified in addiction medicine. Its integrated behavioral health team also includes certified addiction counselors, licensed social workers, and peer recovery specialists. At any given time, some 600 patients are receiving MOUD.

Scott Constantini, the Wright Center’s associate vice president of primary care and recovery supports integration, says having peer specialists as team members is crucial. “Having somebody checking in on patients, keeping them on task, making sure that transportation is set up is critical in the first six months,” as people are trying to stabilize their lives, he says.

The key ingredient in a successful OUD treatment program is a comprehensive team approach. More providers would be willing to offer treatment if they had social workers, peers, and others on their team.

Scott Constantini Associate vice president of primary care and recovery supports integration, Wright Center for Community Health

Rhode Island's Layered Approaches

Programs such as Pennsylvania’s Centers of Excellence have engaged many more providers in offering OUD treatment. But efforts are also needed to reach people who are unlikely or unable to make it into clinics.

Rhode Island has been a leader in this regard. Back in 2016, it launched the nation’s most comprehensive effort to date to screen all incarcerated individuals and offer medication-assisted treatment to those with OUD and other substance use disorders. Nationwide, two-thirds of incarcerated individuals have a substance use disorder; many are left to go through “cold turkey” detox during their sentence, putting them at much higher risk of overdose upon reentry, given their lower tolerance and the lethality of the drug supply.

In just its first year, Rhode Island’s program reduced overdose deaths among people discharged from prison by two-thirds. Many more county jails and state-run prisons have begun offering MOUD for prisoners with OUD, though they are still in the minority. The Biden Administration announced plans to increase the number of jails and prisons offering MOUD by 50 percent in the next two years.

In another initiative, Rhode Island launched a 24/7 hotline that connects people with substance use disorders to a physician who can diagnose OUD and opioid withdrawal over the phone and, if appropriate, prescribe buprenorphine for pick-up the same day and connect people to ongoing care. The state also has a crisis response center in East Providence that is open 24/7 and staffed with nurses, counselors, a psychiatrist, and peers, while Rhode Island’s largest opioid treatment program sends a mobile unit to communities hardest hit by the opioid epidemic.

The changing nature of the drug supply prompted the state to invest more heavily in harm-reduction resources, including a two-year pilot of overdose-prevention centers. The state’s first overdose-prevention center will be attached to an opioid treatment center and have staff and volunteers trained to administer naloxone. With funding from the opioid settlements, the centers will also offer screening for infectious diseases; referrals to social services, including housing programs; and wound care.

Using Data to Reduce Harm and Help Those Most at Risk

Several efforts are underway across the country to use data to track what’s in the drug supply and let health care providers, community leaders, and people who use drugs know about emerging risks.

Researchers from Brown University School of Public Health have partnered with the Rhode Island Department of Health and local harm-reduction agencies to monitor the drug supply using samples donated by harm-reduction organizations and people who use drugs. The results are shared with those who’ve donated the drugs as well as providers throughout the state and publicized over social media.

Other efforts are combining data sources to discern patterns in drug use and opportunities for intervention. Virginia’s Framework for Addiction Analysis and Community Transformation initiative, launched in 2018, enables participating counties to combine local data on OUD, including records of EMS calls for drug overdoses, with a trove of information that states collect and report to the federal government: drug-related arrest records, truancy reports, enrollment figures for opioid treatment programs and food benefits, and vital records on overdose deaths.

Brown researchers are also partnering with the health department to test a new predictive modeling tool that aims to pinpoint at a neighborhood level where overdoses are likely to occur. The tool uses machine-learning to ingest data on drug-related deaths, EMS runs, and opioid prescribing and treatment as well as social factors (e.g., income, employment rates, incarceration rates, and others) in order to predict likely overdose mortality risks.

Investing in Recovery Supports

Given accumulating evidence that OUD is a chronic disease, communities have been developing programs to help people maintain their recovery.

Wilkes Recovery Revolution

Wilkes Recovery Revolution, in North Carolina’s Wilkes County, is what’s known as a recovery community organization, a nonprofit built on the model of peers helping peers; there are nearly 200 such organizations across the country. It was founded in 2016 by Devin Lyall, who in her twenties had to travel to Asheville, two hours away from her hometown and family, to find recovery supports. “When I was ready for help, the services were not here for me,” she says.

With an annual budget of $1.2 million, Wilkes Recovery Revolution operates transitional housing for up to 30 people, who typically arrive from residential treatment programs but are not yet ready for independent living. It also runs a drop-in center where people can meet with certified peer support specialists; take part in support groups or wellness activities; socialize and have meals together; or pick up naloxone and other harm-reduction supplies. Staff also offer people free rides to their MOUD appointments or other activities that promote health and run a mobile recovery unit that enables peers to conduct outreach and offer supports to people in the community.

Wilkes Recovery Revolution staff offer people free rides to their MOUD appointments or other activities that promote health and run a mobile recovery unit that enables peers to conduct outreach and offer supports to people in the community.

Wilkes Recovery Revolution was founded in 2016 by Devin Lyall, who in her twenties had to leave her community to find recovery supports. Among its many programs, the nonprofit runs a farm where people in recovery raise produce. Its mobile recovery health unit travels to rural areas to distribute harm-reduction supplies and connect people with recovery coaching and other supports. 

As part of its efforts to help people in recovery find jobs, the organization launched the Recovery Friendly Workplace Initiative, which has since spread to other parts of North Carolina. The program educates employers about OUD and encourages them to adopt policies that are conducive to hiring people in recovery, such as not requiring drug screens. Several local employers have signed on; Tyson Foods, for example, created an orientation video for new employees that describes substance use disorders and how employees can get help without losing their jobs.

Lyall says these and other efforts have helped community members understand addiction and recovery: “Elevating the voices of lived experience has had the biggest impact.”


As the opioid crisis grinds on, some communities have earned hard-won knowledge about how to engage people in treatment and recovery, and many are stepping up to share promising approaches. The North Carolina Opioid Settlements website offers tools to help local governments evaluate and implement programs to address the OUD crisis and maintains data dashboards to show how much money is available to each county. “We wanted to provide actionable ideas that people can look at and say, ‘This is something we could do,’” says Susan Kansagra, M.D., state health officer and assistant secretary for public health. The National Association of Counties’ Opioid Solutions Center also offers tools and technical assistance to help counties leverage settlement funds, while the Police Assisted Addiction & Recovery Initiative offers training to law enforcement agencies nationwide.

The experiences of vanguard programs point to lessons about how to most effectively put opioid settlement dollars to work.

All hands are needed on deck. Comprehensive approaches require partnerships among health care providers, law enforcement, businesses, people with lived experiences, and others to bring more people into treatment and help them sustain their recovery.

Effective strategies must include not just harm-reduction and treatment services but also programs to prevent OUD and other substance use disorders in the first place. Many people who struggle with substance use start using drugs and alcohol at an early age, making adolescence a critical time to intervene. A recent report from the National Academies for Science, Engineering, and Medicine outlines evidence-based prevention programs and opportunities for pediatricians to talk to their patients about substance misuse and connect them with prevention programs.

Sustainable funding is needed to pay for peer support specialists and others who are key to OUD treatment and recovery. In Wilkes County, $1 million in settlement dollars will be distributed each year by a local coalition, which takes applications for funding from opioid response organizations. While the funds are significant, organizations like Wilkes Recovery Revolution will need other sources of support.

Many state Medicaid programs now pay for the services of peer support specialists to help people with substance use disorders, though they must be certified and work under the supervision of mental health professionals. If more payers covered their work, more people would gain access to recovery supports.

Mechanisms are also needed to support upstream efforts, like Plymouth County’s hubs, in which staff try to prevent people from overdosing or entering the criminal justice system in the first place.

Finally, evaluations are needed to understand what works and to build the business case for promising models of OUD treatment and recovery. After the post-overdose response teams demonstrated success in their first years, Stanly County began paying for part of the costs of the teams, while opioid settlement funds cover some of the other costs.


Making the Most of Primary Care Encounters

In a commentary, Michael J. Barry and colleagues outline several ways that primary care providers can increase the utility of patient visits while minimizing the risk of excessive testing and overtreatment. Among other recommendations, they suggest providers use time spent on performing a “review of systems” (inquiring about symptoms for at least 10 of 14 organ systems) to deliver proven preventive services, such as counseling for smoking cessation, and to engage in shared decision making. The Centers for Medicare and Medicaid Services no longer requires providers to document a review of systems — a practice that the authors say sometimes led to unnecessary workups for patients — and pegs reimbursement to the complexity of medical decision-making or time spent instead. Michael J. Barry and Chien-Wen Tseng, “Moving to More Evidence-Based Primary Care Encounters: A Farewell to the Review of Systems,” Journal of the American Medical Association 328, no. 15 (September 2022):1495–96.

Leveraging Medicaid to Promote Racial Equity

In a high-level analysis, the authors look at who Medicaid programs insure, how the programs are financed, how services are delivered, and which reforms might promote health equity. They find that Medicaid programs have ample opportunities to reduce racial and ethnic health disparities by expanding access to their programs, seeking to reduce disparities within the programs, and focusing explicitly on equity in payment and care delivery reforms. Julie M. Donohue et al., “The US Medicaid Program: Coverage, Financing, Reforms, and Implications for Health Equity,” Journal of the American Medical Association 328, no. 11 (September 2022):1085–99.

A Framework to Align Value-Based Payment with Equity

Efforts to align health care payments with value have done little to advance health equity, and some value-based payment models have exacerbated inequities. In a commentary, Amol S. Navathe and Joshua M. Liao offer a framework to align value-based payment models with goals for health equity. It includes strategies for ensuring safety-net and rural organizations can participate in payment models; setting spending targets that account for patients’ clinical and social needs; and measuring inequities as part of value, among others. Amol S. Navathe and Joshua M. Liao, “Aligning Value-Based Payments With Health Equity: A Framework for Reforming Payment Reforms,” Journal of the American Medical Association 328, no. 10 (September 2022):925–26.

How Well Do MIPS Scores Measure Quality?

This study investigated whether primary care physicians’ scores on Medicare’s Merit-based Incentive Payment System (MIPS) are associated with performance on a broad range of other measures of quality. Based on scores for more than 80,000 physicians, the analysis found that MIPS scores were not consistently related to better performance either on process measures (e.g.., rates of diabetic eye exams or mammography screening) or outcomes (e.g., emergency department visits per 1,000 patients). The researchers also found that physicians with low MIPS scores but superior outcomes cared for more medically complex and socially vulnerable patients, compared with physicians with low MIPS scores and poor outcomes. They conclude that the MIPS program may not be effective at measuring and incentivizing performance improvement. Amelia M. Bond et al., “Association Between Individual Primary Care Physician Merit-based Incentive Payment System Score and Measures of Process and Patient Outcomes,” Journal of the American Medical Association 328, no. 21(December 2022):2136–46.

How Medicaid Programs Can Promote Perinatal Health in the Wake of Dobbs

In this commentary, the authors identify opportunities for state Medicaid agencies to protect and promote perinatal health and family supports in wake of the Dobbs decision. The authors suggest that in the states that are now severely restricting abortion access, Medicaid agencies could strengthen family planning services, including contraception options, and expand postpartum coverage. In other states, Medicaid programs may want to take steps to ensure beneficiaries have access to abortion services, given what may be rising demand from travelers from other states. Mohammad Hussain Dar et al., “Medicaid’s Moment for Protecting and Promoting Women’s Health,” Journal of the American Medical Association 328, no. 21 (November 2022):2105–06.

Did Bundled Payments Lead Hospitals to Avoid High-Risk Patients?

This study examines the effects of Medicare’s Bundled Payments for Care Improvement Advanced Model, in which hospitals are held accountable for the costs and outcomes of a 90-day episode of care. To meet spending targets, hospitals must decrease utilization or attract a relatively healthier patient population; critics worry these incentives could lead hospitals to stint care or avoid patients with complex medical and/or social needs. An analysis of Medicare claims data found no significant changes in patient selection associated with participation in this bundled payment program. Patients who were frail, had multiple conditions, or were dually enrolled in Medicare and Medicaid were more expensive initially, but their payments decreased over time, similar to trends among lower-risk patients. Karen E. Joynt Maddox et al., “Medicare’s Bundled Payments for Care Improvement Advanced Model: Impact on High-Risk Beneficiaries,” Health Affairs 41, no.11 (November 2022):1661–69.

Reducing Discrimination Against Patients with Disabilities

Despite civil rights laws that prohibit discrimination against Americans with disabilities in health care and elsewhere, many people with disabilities continue to experience disparities in health and health care. The authors of this Health Affairs article highlight areas of persistent inequities and suggest potential remedies, including requiring the use of accessible medical diagnostic equipment and communication methods; better standards of data collection; competency training for health care professionals; and non-discriminatory health insurance benefit design. Lisa Iezzoni et al., “Have Almost Fifty Years of Disability Civil Rights Laws Achieved Equitable Care,” Health Affairs 41, no. 10 (October 2022):1371–8.

CPC+ Did Not Yield Cost Savings, Quality Improvements for Commercial Insurers

An analysis of medical claims data from two large insurers in Michigan found that the multipayer Comprehensive Primary Care Plus (CPC+) payment reform model did not reduce spending or improve quality for private-plan enrollees even before accounting for incentive payments to providers. The authors say their analysis adds to existing evidence that CPC+ may cost payers money in the short term without improving care quality. Adam A. Markovitz, Roslyn C. Murray, and Andrew M. Ryan, “Comprehensive Primary Care Plus Did Not Improve Quality or Lower Spending for the Privately Insured,” Health Affairs 41, no. 9 (September 2022):1255–62.

Self-Reported Health Ratings Better in Medicaid Expansion States During the First Year of the Pandemic

Researchers compared self-reported health measures for residents of states that expanded eligibility for Medicaid to residents of states that didn’t and found coverage expansion appears to have offered some protection during the pandemic. In 2020, relative to earlier years, low-income people in expansion states were more likely to report very good or excellent health, fewer days of poor physical health, and lower rates of smoking and heavy drinking than low-income people in non-expansion states. They also saw higher flu vaccination rates in states that expanded Medicaid. The authors note these benefits were particularly salient for Black and Hispanic individuals. Alexandra Rakus and Aparna Soni, “Association Between State Medicaid Expansion Status and Health Outcomes During the COVID-19 Pandemic,” Health Services Research 56, no. 6 (December 2022):1332–41.

Primary Care Medical Home for Patients with Serious Mental Illnesses Yields Health Benefits

As part of a study at the Veterans Health Administration, patients with serious mental illnesses were given the option of receiving psychiatric care from a primary care physician and nurse care manager who consulted with a psychiatrist over phone, instant message, and email. Forty percent opted to do so. Compared with patients who continued to receive medical and behavioral health care from separate providers, those assigned to the primary care medical home were more likely to have appropriate health screenings for body mass index, lipids, and glucose. They also showed greater improvement on measures of chronic illness management (i.e., activation, decision support, goal-setting, counseling, and coordination) and care experiences as well as greater improvement in mental health–related quality of life and psychotic symptoms. Alexander S. Young et al., “The Effectiveness of a Specialized Primary Care Medical Home for Patients with Serious Mental Illness,” Journal of General Internal Medicine 37, no. 13 (October 2022):3258–65.

Use of Patient-Reported Outcomes by Health Systems and Physician Practices Varies by Condition, IT Capabilities

Researchers surveyed 323 health systems and more than 2,000 physician practices to determine the organizational capabilities associated with more extensive adoption of patient-reported outcome measures (PROMs). These measures can be used by clinicians to adjust treatment and deliver patient-centered care. The study found that among hospitals and medical groups within health systems, PROMs for pain and depression were more commonly adopted than ones for disabilities (50.6%, 43.8%, and 26.5%, respectively). In adjusted analyses, systems with more advanced health information technology (IT) were more likely to use disability and depression PROMs than systems with less advanced health IT. They found practices with more chronic care management processes, broader medical and social risk screening, and more processes to support patient responsiveness were more likely to adopt each of the three PROMs. Hector P. Rodriguez et al., “Adoption of Patient-Reported Outcomes by Health Systems and Physician Practices in the US,” Journal of General Internal Medicine 37, no. 15 (November 2022):3885–92.

Unsanctioned Safe Consumption Site for Injection Drug Use Associated with Reduced ED Visits, Hospitalizations

People who inject drugs are at higher risk of infectious disease as well as infections that can produce complications. A study of an unsanctioned, invite-only safe-consumption site where staff provided sterile equipment and administered naloxone to reverse overdoses found people who used it to inject drugs had 54 percent fewer emergency department (ED) visits and were 32 percent less likely to be hospitalized than people enrolled in the study who didn’t use the site. The authors suggest two possible explanations. Participants may have avoided opioid-involved overdoses by being monitored on site or may have been referred to primary care before complications developed. The study also found people using the site had a 24 percent lower risk of overdose within a six-month period, but the results were not statistically significant. They also found that only 12 percent of study participants used the site; among those who did, the median number of visits was 18 over a six-month period. Barrot H. Lambdin et al., “Reduced Emergency Department Visits and Hospitalisation with Use of an Unsanctioned Safe Consumption Site for Injection Drug Use in the United States,” Journal of General Internal Medicine 37, no. 15 (November 2022):3853–60.


Special thanks to Editorial Advisory Board member Anne-Marie J. Audet for her help with this issue.

Jean Accius, Ph.D., senior vice president, AARP

Anne-Marie J. Audet, M.D., M.Sc., senior medical officer, The Quality Institute, United Hospital Fund

Eric Coleman, M.D., M.P.H., director, Care Transitions Program

Marshall Chin, M.D., M.P.H., professor of healthcare ethics, University of Chicago

Timothy Ferris, M.D., M.P.H., National Director of Transformation, NHS England

Don Goldmann, M.D., chief medical and scientific officer, Institute for Healthcare Improvement

Laura Gottlieb, M.D., M.P.H., assistant professor of family and community medicine, University of California, San Francisco, School of Medicine

Carole Roan Gresenz, Ph.D., senior economist, RAND Corp.

Allison Hamblin, M.S.P.H., president and chief executive officer, Center for Health Care Strategies

Thomas Hartman, vice president, IPRO

Sinsi Hernández-Cancio, J.D., vice president for health justice, National Partnership for Women & Families

Clemens Hong, M.D., M.P.H., medical director of community health improvement, Los Angeles County Department of Health Services

Kathleen Nolan, M.P.H., regional vice president, Health Management Associates

Harold Pincus, M.D., professor of psychiatry, Columbia University

Chris Queram, M.A., president and CEO, Wisconsin Collaborative for Healthcare Quality

Sara Rosenbaum, J.D., professor of health policy, George Washington University

Michael Rothman, Dr.P.H., performance improvement consultant

Mark A. Zezza, Ph.D., director of policy and research, New York State Health Foundation

Publication Details



Martha Hostetter, Consulting Writer and Editor, Pear Tree Communications

[email protected]


Source: Martha Hostetter and Sarah Klein, Building Comprehensive Responses to the Opioid Crisis (Commonwealth Fund, Jan. 31, 2023).