Recognizing that EDs are uniquely positioned to engage patients with opioid use disorder (OUD) into effective treatment, Pennsylvania officials decided to test whether financial incentives would be enough to nudge hospitals to facilitate stronger action.

In 2019, the Pennsylvania Department of Human Services created the Opioid Hospital Quality Improvement Program (O-HQIP). Hospitals were given the opportunity to receive incentive payments if they adopted practice changes aimed at increasing the rate of follow-up treatment for Medicaid patients within seven days of an ED visit for OUD.

Under the voluntary O-HQIP, hospitals could receive incentive payments based on their implementation of four specific treatment pathways: initiation of buprenorphine treatment during the ED encounter, a warm handoff to outpatient treatment providers, referral to treatment for pregnant mothers, and inpatient initiation of buprenorphine or methadone treatment.

Hospitals implementing all four pathways received full incentive payments ($193,000), while hospitals that chose to implement three or fewer of the pathways received smaller payments ($25,000 to $108,000).

It is the first state-level, voluntary incentive program aimed at getting patients with OUD connected with appropriate care, and further steps are needed to gauge whether the program is ultimately successful. Early reports suggest higher-level policy-making may offer a valid approach for pushing practice change at the hospital/ED level, particularly when managed in a way that is synergistic with other quality improvement efforts by researchers and frontline clinicians.

Identify Barriers

Seeking to understand the effect of the incentives, investigators from the Perelman School of Medicine at the University of Pennsylvania spoke with hospital leaders from across the state to understand why they did or did not participant in the program. Researchers wanted to learn what barriers continue to prevent certain hospitals from implementing some or all of the identified pathways.1

In terms of overall participation, researchers consider O-HQIP a success, as at least 80% of the hospitals in the state chose to implement at least one of the designated pathways, explains Austin Kilaru, MD, MSHP, lead author of this research.

“Certainly, there is a great deal of interest among hospitals and EDs in developing a system to provide warm handoffs,” he says.

Still, Kilaru and colleagues found many of the hospitals were reluctant to initiate buprenorphine treatment during an ED encounter, citing resource or operational barriers. “It was just harder for some of the hospitals to want to undergo the changes necessary, and to justify those changes based on the volume of the patients they were seeing,” observes Kilaru, a fellow at the Center for Emergency Care and Policy Research at the Perelman School of Medicine.

Further, some physicians were reluctant to prescribe buprenorphine because they were uncertain whether patients would continue with their treatment once they left the ED.

“There was the barrier of starting the medicine without knowing ultimately what the subsequent [treatment] destination of the patient would be,” Kilaru shares. “That issue was somewhat mitigated by the other pathways [focused] on creating partnerships between EDs and external facilities. The stronger those partnerships became between the ED and long-term treatment [providers], EDs were more willing to adopt that pathway.”

In speaking with hospital leaders, Kilaru and colleagues also heard a lot about stigma attached to prescribing buprenorphine. “There was the thought that EDs are not necessarily in the business of prescribing chronic medications for patients. Some EDs didn’t want to become a place where this kind of treatment was available,” Kilaru relates.

While some hospital representatives raised the issue of stigma, barriers related to operational training and management issues were cited more frequently when discussing why they declined to implement one or more of the treatment pathways.

Form Partnerships

Interestingly, payments aligned with implementation of the treatment pathways were a single, one-time process incentive designed to motivate hospitals around the state to think about how to deliver care for patients with OUD.

“The overall goal of this program is to get as many people to treatment after an ED visit for OUD as possible,” Kilaru says. “The pathways themselves were stepping stones or guidelines for ways of doing that ... but [going forward], hospitals are being incentivized from year to year for improvement, regardless of the pathways.”

To be more specific, the more patients who are afforded treatment following an ED visit for OUD, the better hospitals will fare in terms of incentive payments.

“It is more about the rate of follow-up encounters. Prescriptions for buprenorphine are one of the things that the state is looking for in terms of counting that rate, but the pathways were a way of launching the whole program,” Kilaru explains.

Still, it is clear the modest pathway-aligned incentives were enough to prompt hospitals to put systems in place directed toward connecting OUD patients to effective treatment. One of the big lessons was the importance of engaging with external partners.

“We found that a lot of the hospitals that implemented pathways ... really tried to strengthen that linkage [with a community treatment provider] so they could communicate in real time when there was a patient in the ED who would need follow-up care,” Kilaru says.

Another key lesson was the value offered by peer recovery specialists. These were personnel often engaged by community providers. In some cases, they would come to the ED when a patient there required OUD treatment. “That [peer recovery specialist] navigating and solving issues over time was seen as really instrumental in getting these patients into care, and motivating patients to get into care as well,” Kilaru notes.

Now that hospitals and EDs are incentivized on annual performance improvements, it remains to be seen whether the O-HQIP will make a serious dent in moving more patients with OUD into treatment and reducing overdose deaths.

However, Kilaru notes this is one example of how higher-level policy can prompt rapid practice change while also “giving [clinicians and administrators] the flexibility to do what works best for them at their own hospital.” 


  1. Kilaru AS, Lubitz SF, Davis J, et al. A state financial incentive policy to improve emergency department treatment for opioid use disorder: A qualitative study. Psychiatr Serv 2021 Feb 17;appips202000501. doi: 10.1176/ [Online ahead of print].