Rachel was making her 25th visit to the emergency department. The wound on her leg from injecting drugs had spread to her entire calf and required a lengthy course of antibiotic treatment in the hospital. The few times she had been admitted to the hospital, she had left without finishing treatment because the pain and withdrawal symptoms were too much to bear. On her most recent visit, she finally stayed to complete the treatment. She was then connected to an outpatient program to receive medication for her addiction, where she met Tara.
Tara introduced herself to Rachel as someone who once used drugs and now helps people like Rachel get back on their feet. In the following months, Rachel agreed to participate in a research study to receive support from Tara and a social worker.
Tara checked on Rachel at least weekly. Rachel was too ashamed of her chaotic life to let her family know her whereabouts. At Tara’s encouragement, she left the street and went back to her family. When Tara found out that Rachel’s family was spending hundreds of dollars each month ordering wound care supplies from Amazon, she worked with Rachel’s doctor to send Rachel supplies fully covered by Medicaid. Tara helped Rachel re-enroll in Medicaid, apply for food stamps, and get a mailing address at a local program serving people who are homeless and use drugs. They talked about how Rachel might find purpose after a decade full of shame and trauma. Rachel is now thinking of going back to school.
The last time they talked, Tara told Rachel that the study that had funded Tara’s work for four years was ending. The medical center had yet to find the money to continue the program that had supported Rachel so well.
We are a health policy researcher, a provider with lived experience, and a physician caring for patients with addiction. We are all too familiar with how the American health care system strains to tackle the opioid crisis yet barely makes use of professionals like Tara who know the disease intimately.
In the U.S., the opioid crisis claimed more than 81,000 lives last year. An estimated 2.7 million individuals struggle with opioid use disorder, a chronic condition with huge human and societal tolls. The struggle is so difficult, and the associated stigma so deeply entrenched, that care delivered by traditional providers, like doctors, nurses, and mental health clinicians, is not enough.
Professionals like Tara are known as “peer recovery specialists” or more simply, “peers.” Peers are living testimonies that recovery is possible. All 41 states that cover peer services through Medicaid require peers to be trained, certified, and supervised. Peers spend a lot of time with patients, but also in texting, calling, and working with the patient’s doctors, and finding patients community resources.
Research studies have shown promising but inconclusive evidence on the effectiveness of peers in helping people like Rachel. Peer programs vary considerably in how peers are trained, what activities they engage in, and where and with whom they work. Such variation adds to the difficulty of generating definitive research evidence. However, waiting for research data to coalesce before deploying a promising approach is a luxury that we do not have in this raging crisis.
In a recent study, our team examined Medicaid billing records for peer services. In 20 out of the 28 states we studied, less than 5% of patients with opioid use disorder in 2019 ever received Medicaid-reimbursed peer services. Patients who received any peer services typically received them on 1 or 2 days over the entire year. If Rachel were one of those patients, her first encounter with Tara likely would have been the last.
The very limited use of peer services we observed may have a lot to do with how Medicaid typically pays for peer services. It’s based on the time peers spend with a patient, and the payment rate for every 15 minutes can be as low as $10 for one-on-one sessions and $3 per patient for group sessions. Peers like Tara are passionate about caring but they can’t do their job with such low pay.
The low payment rate is only part of the problem. To help patients like Rachel, Tara spends way more time searching for and coordinating services and supports without the patient present as she does with the patient. Medicaid won’t let her bill for that time. That time is just as important to patient recovery as are personal encounters. Medicaid should move from paying for time with a patient to paying for all things peers do for a patient. One approach is a per-patient-per-month payment, known as a case rate. It covers all activities needed to support recovery and allows peers maximum flexibility in deciding when to do what and where. To make such a payment work, however, it will need to be designed in a way to ensure minimum quantity and quality of services.
Medicare, many Medicaid programs, and some private insurance plans already have a case rate payment for a team to manage primary care patients with mental health conditions such as depression. Teams supported by these payment models typically do not include peers but can benefit from doing so, especially for patients battling both mental health problems and addiction, as in the research study that hires Tara. Another strategy is simply to increase the per-15-minute rates for peer services, which, though unlikely to be sufficient, will at least move us in the right direction.
In the war against the opioid crisis, the healing power of peers is too precious to forego. To unleash peers’ potential, we need Medicaid to change the way they pay peers and give all patients like Rachel the hope and dignity to begin the series of life-changing events known as recovery.
Yuhua Bao is a professor of population health sciences at Weill Cornell Medicine in New York City. Her research focuses on two key themes: aligning provider payment models with evidence-based care for mental health and substance use conditions and analyzing policies addressing the opioid crisis. Dr. Bao is leading programs at Cherish, a NIDA Center of Excellence (P30), and is part of the Cornell Health Policy Center. She can be reached on X @yuhuabaophd.
Tara Calderbank is a certified recovery specialist and manager. Rebecca Arden Harris is a family physician.
