Lessons Learned? What New Hampshire can Learn from Vermont in “Hub and Spoke” Model of Opioid Treatment

Abstract

Vermont had 13.9 overdose deaths per 100,000 people in 2014, almost 2.5 times less than New Hampshire in the same year (Rudd 2016). Much of this has been attributed to the framework Vermont has in place for treatment of Opioid Use Disorder (OUD), specifically the “Hub and Spoke” model of treatment. This model has been highly praised due to the continuity of care waivered spoke physicians are able to provide, and the overall success the program has had in reducing overdoses and addiction as a whole, typically through the “gold standard” of Medication Assisted Treatment (MAT). “The Doorway” as the hub and spoke system is called in New Hampshire, is realistically a referral framework that links people seeking treatment with OUD to a provider, which is very different from the structure in Vermont. Vermont is predicted to spend about $85 million of Medicaid money on treatment for people with OUD in 2019 (Table 1). Meanwhile, New Hampshire, a state with over double the population, is projected to spend $52 million in 2019 (Table 2). This is likely due to differences in Medicaid payment structure and MAT-waivered physician availability; Vermont has a larger rate of MAT providers per 10000 population of 2.71 compared to 2.05 in New Hampshire. New Hampshire Medicaid reimburses behavioral health providers poorly, providing an indexed reimbursement rate of 0.83 in comparison to 1.11 in Vermont (Kaiser Family Foundation 2019). To initiate change and create a treatment utilization rate equivalent to Vermont, it is estimated New Hampshire would have to spend $133 million to $150 million in 2019, which is not possible given the taxation structure in place.