F11.20^*

Matthew Murphy (MD, MPH)
Assistant Professor of Medicine and Behavioral
and Social Sciences / Brown University
Medical Director / Rhode Island Public Health Institute
Staff Physician / Rhode Island Department of Corrections

Every healthcare system has its challenges, but in the United States the opioid epidemic is, in many ways, the product of a structurally dysfunctional organization of health services and institutions. The foundational flaw in the US health system is its focus on the treatment of diseases and disorders instead of people and their priorities for their own health. Guided by a predominantly biomedical approach to healthcare that prioritizes highly specialized clinical services, hospitals, clinics and other healthcare facilities have historically been funded using a disease-specific, fee-for-service system.

The way we fund healthcare in the US has led to siloing, fragmentation and competition among various entities. It places a significant administrative and organizational focus on diagnosis codes linked to each clinical encounter, test and treatment generating revenue for the associated health service entity. There are a number of problems with this method of financing, and while the Affordable Care Act (ACA) introduced preliminary reforms, efforts to address the opioid epidemic will continue to be undermined if the way we fund healthcare is not significantly revised or overhauled altogether.

The treatment of opioid use disorders (OUD) has been historically relegated to methadone clinics that focus on meeting the billing requirements for diagnosis codes such as F11.20, which indicates severe opioid use disorder. As a result, methadone clinics operate in a uniquely complex billing, legal and administrative milieu that limits their ability to provide care other than opioid replacement therapy. This siloing also contributes to the stigma associated with OUD, along with the location of methadone clinics. While progress has been made in integrating the care of substance users into other health services, the treatment of OUD often happens in a vacuum and fails to address other health needs or co-occurring conditions.

Rethinking the dysfunctional approach to funding healthcare in the US would arguably have a more powerful impact on controlling the opioid epidemic than sticking with the status quo. This requires building on the initial work of the ACA to move away from disease-specific, fee-for-service reimbursement towards people-centered payment structures informed by public health needs.

If we hope to address many of the country’s public health priorities that intersect with the opioid epidemic—including ending the HIV epidemic, eliminating Hepatitis C and reversing the inequitable impact of the COVID-19 pandemic—our healthcare system must implement funding mechanisms that recognize people and patients as more than just billing codes for diseases.