RESUMO
Despite telehealth's potential to improve access to care, it is underutilized by safety-net providers, including Federally Qualified Health Centers (FQHCs), due to a range of policy, organizational, and logistical barriers. Research that facilitates state-to-state learning can inform both Medicaid and Medicare policies going forward and provide lessons learned for FQHCs interested in starting or expanding telehealth programs. The authors conducted telephone discussions with representatives of seven state Medicaid programs and 19 urban and rural FQHCs to address how FQHCs in selected states are using telehealth, how the delivery of telehealth services is structured, barriers and facilitators of telehealth, and how Medicaid policy influences telehealth implementation. Live video telehealth, typically telebehavioral health, was the most prevalent type of telehealth among FQHCs in the sample. Stakeholders highlighted several weaknesses of Medicaid policies in one or more states, including general lack of clarity regarding which services were allowed by Medicaid programs, ambiguity around telepresenter requirements, lack of authorization for FQHCs to serve as distant sites in the federal Medicare program and in select state Medicaid programs, and insufficient reimbursement. FQHC stakeholders also identified multiple barriers to telehealth implementation beyond reimbursement. Nonetheless, FQHC stakeholders generally believed they could overcome these various barriers to telehealth implementation, if reimbursement and the risk of losing revenue in offering telehealth services were improved. While diversity of experiences makes it difficult to generalize about implementation of telehealth in the safety net, the authors identified several common themes and associated considerations for policymakers, payers, and FQHCs.
RESUMO
This systematic review addresses the question: What are the effects of medication-assisted treatment (MAT) that use buprenorphine, buprenorphine combined with naloxone, methadone, or naltrexone for opioid use disorder (OUD) on functional outcomes compared with wait-list, placebo, treatment without medication, any other comparator, or each other (e.g., buprenorphine versus naltrexone)? Functional outcomes investigated included cognitive (e.g., memory), physical (e.g., fatigue), occupational (e.g., employment status), social/behavioral (e.g., criminal activity), and neurological (e.g., balance) function. The authors searched five scientific research databases from inception to 2017 and reference mined existing reviews. Two independent literature reviewers screened 6,292 citations; 1,327 full-text publications were reviewed in detail and 37 studies met inclusion criteria. Critical appraisals assessed studies in detail, and quality of evidence was rated using established criteria. Results were synthesized in meta-analyses and presented in comprehensive evidence tables. Although MAT patients performed significantly better on some functional outcomes than persons with OUD who did not receive MAT, MAT patients performed worse on several cognitive measures than did matched "healthy" controls with no history of substance use disorder (SUD) or OUD. Because of the moderate-to-high risk of bias of most studies, quality of evidence is low or very low for all findings. The small number of studies reporting on outcomes of interest and the weaknesses in the body of evidence prevent making strong conclusions about MAT effects on functional outcomes. The literature shows that more research is needed that targets functional outcomes specifically, and there is, in particular, a lack of research evaluating potential differences in functional effects among medication types, the route of administration, treatment modality, and length of treatment.
