Numbers tell the story in Vermont Hub and Spoke

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Color-coded map, part of Vermont’s 2015 network analysis research, illustrates the connectivity among Bennington, VT, hub-and-spoke services. Illustration/blueprintforhealth.vermont.gov

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Editor’s note: Third part of an ongoing series of stories over the next several weeks by the Granite News Collaborative reporting on NH’s new Hub and Spoke network of mental health, addiction and crisis services.


By all measures, Vermont’s Hub and Spoke System has been a significant success.

It is a self-sustaining program that has contributed to more people getting treatment per capita in the state, a reduction in opioid-related deaths and no wait times for people seeking treatment, according to Mark Levine, the commissioner of Vermont’s Agency of Human Services.


Part of the reason they were so successful is that they tweaked their laws, used expanded Medicaid to invest money in adding spokes, and made a huge push to get more practitioners authorized to prescribe buprenorphine to a higher number of patients.

Here’s a roundup of Vermont’s accomplishments:

  • Increasing number of residents receiving treatment and capacity: In 2017, Vermont had 6,604 patients who were receiving Opioid Agonist Treatment —treatment using either Methadone or Suboxone — out of a total population of 625,000 people, according[AB1]  to a 2017 report published in the Journal of Addiction Medicine.

That represented 1.05 percent of all Vermonters or 10.56 people treated per 1,000 people. Five years earlier, only up from 3.76 people per 1000 were getting this sort of treatment, according to the 2017 report.

  • Reducing doctor wait time: The hub-and-spoke program in Vermont has also reduced the doctor wait time substantially, according to the 2017 Vermont Blueprint for Health Annual Report: “Last year [2016], this report noted that the statewide waitlist had fallen below 500 for the first time,” the report said. “As of September 20, 2017, the statewide wait-list had dropped to 110.”

And, as of mid-February this year, Levine said there were no wait lists anywhere in the state.

  • Driving costs down: The Vermont Hub and Spoke model has also driven costs down, according to cost impacts assessed by the Vermont Child Health Improvement Program (VCHIP).
Adapted from https://blueprintforhealth.vermont.gov/

Before the expansion of medication-assisted treatment in Vermont in 2012, individuals with at least two claims for opioid use or dependence in a calendar year had healthcare costs derived from Medicaid Claims Data that were higher than those without claims. Since 2013, these overall healthcare costs, including the cost of the treatment itself, have dropped by 7 percent to 10 percent.

  • Investments in treatments equal savings: The “Vermont Results” report estimates that for every dollar the state spends on hub-and-spoke, it gets $1.12 back in employment earnings, payment of income taxes, and crime reduction, among other savings.
  • Reducing substance use for clients: The University of Vermont’s Center on Behavior and Health conducted its own study, published in December 2017, entitled, “Vermont Hub-and-Spoke model of Care for Opioid Use Disorders: An Evaluation.” For the report, study authors interacted with 100 self-selected opioid addicts, 80 of whom were getting treatment from the hub-and-spoke program and 20 who were not. According to the report, “Out-of-treatment participants showed no statistically significant change in any measure of functioning, including drug use, over 12-month period.

“In contrast, the in-treatment group has statistically significant positive changes in nearly every measure between the time of treatment admission and interview for this study, an average of approximately 30 months. Average days of opioid use decreased from 86 of 90 days to 3 of 90 days, a reduction of 96 percent. Days of injection use decreased by 93 percent. Alcohol, tobacco, and illicit drug use, with the exception of marijuana, all showed significant reductions.”

  • Reducing health care costs for individuals in treatment:  “Health-care expenditures are significantly lower for participants in the medically assisted treatment program than for those not enrolled,” Vermont State Rep. James Gregoire, a member of General Assembly’s Human Services Committee, wrote in a column for the St Albans Register. “In 2016, MAT-enrolled per capita healthcare expenditures were $7,938 while non-MAT per capita healthcare expenditures were $12,532. Incarceration rate for MAT participants was about two-thirds of that of non-MAT opioid-addicted individuals.”

According to the “Vermont Results” report, in fiscal year 2016, 86 percent of hub services were paid by Medicaid and 7 percent of patients were uninsured. An estimated 68 percent of those in spokes are on Medicaid. Uninsured individuals are served in hubs.

The 2017 Blueprint for Health annual report says the number of Medicaid patients getting MAT in Vermont spokes had grown from 1,837 in March 2013 to 2,606 in September 2017. Since the hub-and-spoke program started, the total number of spokes staff hired equaled 63 full-time equivalents by September 2017.           


Challenges

  • Staffing levels and authorization to prescribe buprenorphine;
  • Accurate data collection;
  • Continued evaluation of drug abstinence and cost outcomes for the model.

According to the 2017 report in the Journal of Addiction Medicine, “The primary challenges encountered during implementation of the Vermont hub-and-spoke system include staffing shortages, particularly among nurses and clinicians, and difficulty ensuring accurate data collection across a network of treatment sites.”

There are also still areas in the state with few buprenorphine prescribers. Efforts are underway to change this, with the University of Vermont Medical Center supporting buprenorphine education with medical students and residents.

Additional efforts are also needed to evaluate the drug abstinence and cost outcomes associated with the hub-and-spoke model, and also to establish the validity of the [Treatment Needs Questionnaire] for assessing patients’ treatment needs.”


GRANITE SOLUTIONS HUB AND SPOKE STORIES

Part 1: NH’s Hub and Spoke System: Traction or just spinning wheels?

Part 2: Safe, for now: Future of Safe Station not clear in wake of hub-and-spoke

Part 3: Numbers tell the story in Vermont hub-and-spoke


This story was produced by The Granite State News Collaborative as part of its Granite Solutions reporting project. For more information visit www.collaborativenh.org. Next week, we will take a deep dive into the issue of Medicaid Reimbursements and what’s being done to address the issue.