Health Plan Disenrollment After MOUD Initiation Tied to Higher Mortality in US Cohort
Key Clinical Summary
- In a cohort of 20,011 US patients initiating buprenorphine or naltrexone, 34.7% experienced health plan disenrollment within 2 years.
- Disenrollment was associated with higher adjusted risks of all-cause mortality (HR, 1.51) and overdose mortality (HR, 1.56).
- Both disenrollment and remaining enrolled without receiving medications for opioid use disorder (MOUD) were linked to markedly increased overall mortality risk.
Health plan disenrollment after initiation of medications for opioid use disorder (MOUD) is associated with significantly increased all-cause and overdose mortality, according to a cohort study published in JAMA Psychiatry. The findings underscore the potential dangers of insurance coverage disruptions for patients receiving treatment for opioid use disorder (OUD).
Study Findings
The researchers examined privately and publicly insured patients aged 16 years or older who initiated buprenorphine or naltrexone for OUD between January 1, 2012, and December 31, 2021. Participant electronic health records and claims data were extracted from 3 integrated health insurance and delivery systems in 2 US states, and cause of death information was retrieved from the National Death Index. Participants were followed for up to 2 years, until death, or until the end of the study, depending on which occurred first.
Among 20,011 patients (mean age, 38.7 years; 61.5% male), 6948 (34.7%) experienced health plan disenrollment during follow-up. A total of 586 patients (2.9%) died. The crude rate of all-cause mortality was 15.3 per 1000 person-years (95% confidence interval [CI], 14.1–16.6), and overdose mortality was 6.2 per 1000 person-years (95% CI, 5.4–7.0).
Patients who ever experienced disenrollment had higher mortality rates than those who remained continuously enrolled. The rate of all-cause mortality was 17.6 versus 14.7 per 1000 person-years, and overdose mortality was 8.9 versus 5.4 per 1000 person-years.
In adjusted survival analyses accounting for sociodemographic and clinical factors, disenrollment was associated with increased hazards of all-cause mortality (hazard ratio [HR], 1.51; 95% CI, 1.23–1.84) and overdose mortality (HR, 1.56; 95% CI, 1.17–2.09).
Those who were disenrolled had a more than fourfold higher risk of overall mortality (HR, 4.34; 95% CI, 3.19–5.89) compared with patients who remained enrolled and received MOUD. Similarly, patients who remained enrolled but were not receiving MOUD also had elevated mortality risk (HR, 4.19; 95% CI, 3.24–5.43).
Clinical Implications
The findings highlight continuity of health insurance coverage as a critical factor in the management of OUD. Disruptions in coverage may interrupt access to MOUD, primary care, and other supportive services, potentially increasing vulnerability to relapse, overdose, and death.
Mortality risk was substantially higher not only among those who were disenrolled but also among those who remained enrolled yet were not receiving MOUD. This suggests that both insurance continuity and sustained engagement in treatment are essential components of reducing mortality risk.
For clinicians, the data reinforce the importance of proactively addressing insurance transitions with patients, especially during known periods of coverage instability.
Expert Commentary
“Strategies are needed to address risks associated with insurance-related transitions and improve retention for patients receiving MOUD,” wrote Anh P. Nguyen, PhD, Institute for Health Research, Kaiser Permanente Colorado, Aurora, and study coauthors.
The researchers noted that the study does not establish a causal link between disenrollment and mortality, underscoring the need for future research to further examine the association.
