States are scrambling to patch together workable solutions to support the pandemic response, but we continue to ignore the epidemic that has killed nearly half a million Americans in the past decade and leaves a nearly 20 million Americans aged 12 and older battling substance use disorder.
The percentage of ED visits with an overdose diagnosis has increased by 34.1% since last June, according to an analysis of Collective Medical data from more than 500 hospitals in states across the country.
What makes this data more significant is that overall hospital volume during this period was slashed by more than half. Social distancing, isolation and uncertainty may have contributed to an increase in substance use disorder, and despite overall avoidance of hospitals during the nationwide lock-down, hospitals saw record increases in overdoses.
A patchwork of technology infrastructure
In 2017, 47,000 people died from an overdose. In the same year, the Trump Administration declared the opioid epidemic a public health emergency, at which point the epidemic had been raging for more than a decade.
There were some early indicators that Federal efforts were paying off: Data from 2018 showed a modest decrease in opioid overdose deaths. But according to early data from the CDC, deaths rose again in 2019. The opioid public health crisis has been uncontrolled for years, and any progress made may have already been erased by the fallout of the COVID-19 pandemic. According to the American Medical Association, more than 35 states have reported increases in opioid-related mortality.
The other 'second wave'
While pharmaceutical companies and physician prescribing habits are often blamed solely for the opioid epidemic, an article published in the Journal of American Public Health Association argues that “the crisis is fundamentally fueled by economic and social upheaval, its etiology linked to the role of opioids as a refuge from physical and psychological trauma, concentrated disadvantage and hopelessness.”
Unfortunately, these are exactly the pandemic-fueled current conditions within the United States.
The American Medical Association released an issue brief raising concerns for increasing number of opioid related mortality across the country, with specific policy considerations for removing barriers to access to care and programs that require in person access points that may be limited or impacted by reduction in travel and rising unemployment.
States bear the burden of the public health response, both for the pandemic and the opioid epidemic, but they are financially devasted and ill-equipped to build the systems needed to monitor and report on healthcare needs, much less impact care delivery.
SUPPORT to address an epidemic
States are currently supported in technology infrastructure development via 90/10 funding, which assumes a state can fund 10% of the cost of a public health technology project. But according to the Urban Institute, state tax revenues collapsed by half in April. Some states, like Ohio, are chopping budgets by up to 20%. With the burden of pandemic response shifted to states—not considering the increase in overdoses and SUD diagnoses—they are responsible for building the technology systems needed to effectively mitigate a global infectious disease outbreak. But most will be left to scratch for nickels.
Support from the federal government is a necessity to ensure states can effectively combat the current COVID-19 pandemic and manage the forgotten opioid crisis.
There are several viable options the federal government can make available to states. The Substance Use–Disorder Prevention that Promotes Opioid Recovery and Treatment for Patients and Communities Act (the “SUPPORT Act”) was passed in 2018. Stakeholders agree that the law has been an important step forward, offering a range of policies to prevent new addictions and to expand access to treatment, including medication-assisted treatment.
The SUPPORT Act has been assistive in supporting overarching goals to strengthen and expand evidence based applications, access to technology to support communication between providers, prescription monitoring programs, event notification services and telemedicine interventions. Notably, funding is overseen by Medicaid—which also oversees billions administered for interoperable health information exchange as part of the HITECH Act of 2019—ensuring that technology projects built adhere to the standards for interoperability developed by the US Department of Health and Human Services.
The law is also notable for what it does not include. Most prominently, a major, sustained infusion of new funding to expand community-based care for substance use disorders. Its funding expires in a few short months, on September 30, 2020.
Good policy, bad timing
Looking forward, there is a good policy framework from the SUPPORT Act that could be repurposed and would benefit the COVID19 response and infrastructure and provide a path forward for states to start to manage both crises.
Those working in the aggregation of COVID-19 data for Public Health know that the infrastructure needed for COVID-19 must be enduring, multipurpose and comprehensive. Despite the sunset of its funding, the SUPPORT Act provides the right policy framework to enable the right infrastructure, engage all required stakeholders, involve multiple agencies and ensure that technical investments are not limited to a single use case.
Leveraging the good work forged by the SUPPORT Act, there are steps government leaders can take to help states prepare for public health crises. While drafting the next COVID-19 relief package, lawmakers can increase the federal matching rate that would otherwise apply to a state under section 1903(a) for FY2020-FY2022 to 100% for public health systems for Medicaid providers.
This funding would ensure any technology investments meet the interoperability criteria in section 3004 of the Public Health Services Act described in 45 CFR Part 170, which help in the screening, testing and treatment of communicable diseases and vaccine preventable diseases. There is a precedent for this language in Section 5042 of the SUPPORT Act for opioid technology.
Healthcare technology meaningfully impacts opioid use disorder outcomes.
We know that investments in health data and clinical interoperability work and with support from the federal government, states can expand upon solid outcomes achieved over the past several years and leverage this infrastructure to not only tackle the acute pandemic response but address the swelling opioid epidemic head on.
The state of Washington: The Brookings Institution evaluated and reviewed the results achieved by Washington state one year after implementing a technology infrastructure and network as part of a program called “ER is for Emergencies.” The review found that after one year, statewide, there was a:
- 10% drop in total Medicaid ED visits year-over-year
- 24% reduction in ED visits with an opiate prescription
- $34 million in savings to the state
The commonwealth of Virginia: The commonwealth launched a statewide technology solution and network connecting all 106 hospital emergency departments within six months. The program, the Emergency Department Care Coordination Program (EDCC), administered by Virginia Health Information, focuses on reductions in avoidable emergency department utilization and opioid prescriptions, and earlier identification of patients at risk of substance use disorder.
- For the first time in six years, fatal opioid overdoses in Virginia dropped rather than increased.
- Giving medical providers access to critical patient information in real time may have helped decrease fatal opioid overdoses from 1,230 in 2017 to 1,213 in 2018.
- Additionally, all fatal drug overdoses in Virginia dropped from 1,536 in 2017 to 1,484 in 2018.
Public health technology makes a difference. But it is difficult and costly to implement.
States, bearing the burden of the public health response, are financially strapped and lack the staff resources and expertise needed to stand up these systems. Keeping each state’s response unique to the needs of its citizens, the federal government needs to take action to fully fund public health infrastructure following the standards developed by HHS. This will prepare states and healthcare providers not just for the COVID-19 response, but let them address the long smoldering and lethal opioid epidemic.
Jaime Bland is chief executive officer of the Nebraska Health Information Initiative (NEHII). Kat McDavitt is chief, external affairs of Collective Medical.