As more adults over 65 develop chronic substance use problems, the landscape of available options, particularly for those who receive Medicare, is also rapidly changing.

Deadly drug overdoses quadrupled for older adults between 2002 and 2021, but among Medicare beneficiaries with a substance use disorder (SUD), fewer than one in five receive medication-assisted-treatment (MAT). 

Opioid use, in particular, is growing as a SUD among Medicare seniors. Around one million Medicare beneficiaries had an opioid use disorder in 2020, according to the Health and Human Services Office of the Inspector General. Yet fewer than 16% received treatment.

Establishing parity in mental health rules for Medicare to expand SUD coverage and, ultimately, access is also facing new headwinds from the Trump administration. The Biden-era rule that strengthened the Mental Health Parity and Addiction Equity Act mandated that coverage for SUDs be comparable to that of physical health conditions. The new administration is considering rolling that back, which would decrease access and increase out-of-pocket costs for Medicare recipients in need of that care.

That could lead to an even higher number of older adults with SUDs going untreated. As rates rise and access hangs on the edge for this population, identifying and filling gaps is where providers’ focus will need to be, experts told Behavioral Health Business.

Collaborating to fill a growing need

Medicare coverage gaps for SUD treatment are not new. Care for seniors with addiction is evolving, with improved screening techniques now helping connect patients to treatment more proactively, even as the policy landscape changes.

“Preventive medicine is so much less expensive. If we talk to this population in a way where we are asking curious questions, we may identify something way before it has implications,” Dr. Amy Swift, addiction physician and deputy CMO at Silver Hill Hospital, told BHB. “We can prevent it from escalating to a use disorder – that, in and of itself, is a cost-saving measure.”

Higher rates of medication prescription in general, which is common among older adults who often develop chronic conditions or various needs as they age, automatically opens the door for higher rates of possible exposure to addictive medications. Asking thoughtful, open-ended, nonjudgmental questions during regular primary care visits and other opportune points in their care continuum is one way to proactively help Medicare beneficiaries address SUD conditions.

“I would say that a large priority should be for equitable screening for SUD in this population – if you don’t identify it, you can’t treat it,” Dr. Kimberly Beiting, assistant professor of medicine in the division of geriatric medicine at Vanderbilt University Medical Center told BHB. “All providers should be comfortable with the administration of naloxone for opioid overdose reversal and education regarding the use of buprenorphine to treat opioid use disorder should be prioritized.”

Doing this in practice regularly, however, requires better care coordination – a gap that pressingly needs to be addressed, Dr. Lauren Kelly, assistant professor of geriatrics and palliative care at the Icahn School of Medicine at Mount Sinai, explained.

“For patients with substance use disorders, particularly those on long-term methadone maintenance for 20-30 years, the medical providers they see in opioid treatment programs are focused on addiction treatment rather than providing comprehensive primary care,” Kelly told BHB. “They don’t necessarily have someone who is a quarterback for all of their different medical conditions. It can be very overwhelming for a patient to have to manage multiple health issues on their own.”

Medicare introduced CPT codes to bill for collaborative care management in 2017 as an incentive for reimbursement when a behavioral health care manager provides care to a beneficiary with the supervision and coordination of a primary care physician and a psychiatric consultant. In practice, these have been underutilized.

 “Collaborative care management was built to create incentives for primary care organizations to engage and integrate behavioral health and SUD treatment into their practices,” Dr. Traci Sweet, co-founder and chief operating officer of Holon Health, said. “It is still underutilized. But it is important to be able to deliver behavioral health and SUD into primary care organizations.”

If an organization is unable to internally integrate collaborative care in this way, they have a responsibility to look externally, she said, and hire external partner organizations to provide care management services, consulting psychiatric services for this patient population. Doing this more and more “is going to become a gold standard,” Sweet added.

Richmond, Virginia-headquartered Holon Health is a mental health provider that specializes in addiction treatment and serves patients in three states. The company is slated to soon add services to six additional states.

Creating models of care that work

A body of research developed by Dr. Benjamin Han, a geriatrician, addiction medicine physician and clinician-researcher at the University of California, San Diego, emphasizes not only enhanced screening for older adults with SUDs and aligned training for providers on such but also care that focuses on physical function for this population to improve treatment access.

He also calls for a broad transformation of the healthcare system.

“The U.S. healthcare system must transform to deliver age-friendly care that integrates evidence-based geriatric models of care incorporated with substance use disorder treatment and addresses the intersectional stigma this population has experienced in healthcare settings,” Han wrote in the conclusion of a 2024 study on older adults with OUDs. 

While the prevalence of SUDs continues to increase among Medicare seniors, so too does the prevalence of co-morbidities. Issues with mobility, cognition and other ailments can also be barriers to accessing treatment. Taking into account the “five Ms” is key to any approach in caring for this population, Kelly explained.

Mind, mobility, medications, multicomplexity, and what matters most are part of a framework specifically designed to encourage patient-centered care for older adults. When it comes to SUD care for Medicare beneficiaries, incorporating these as a part of integrated care can lead to better outcomes.

“The key is balancing the different health conditions these patients have while ensuring that care is well-coordinated,”  Kelly said. “Integrated models of care hold promise, but within those models, we need to identify who is effectively managing care coordination and how we can scale and replicate that. Right now, no one seems to have a sustainable solution.”

Before joining Vanderbilt University Medical Center to develop a geriatric consult and primary care clinic within the Vanderbilt Recovery Clinic, Beiting worked with this population in a duet-style program as part of Symphony Care Network. Under this model, patients with dual diagnoses like SUD and other medical illnesses have access to certified drug addiction counselors on-site. These individuals also help run group therapy and coordinate addiction care, which was a successful care model for this patient population, she explained.

“I would also say any home-based or mobile treatment programs (e.g., recent regulations that have allowed methadone clinics to run methadone treatment vans in the community) or telemedicine treatment programs, both of which were flexibilities adopted during the pandemic and formalized this year, also are more senior-friendly,” Beiting said. “Basically, care models that integrate complex care, aging, harm reduction and SUD care for older or complex patients tend to have the most success.”

Where the gaps remain

These models, however, are ideal and not always widespread or accessible for seniors with SUDs. Specifically, when it comes to Medicare, restrictions to how and where seniors in need receive addiction care are ongoing barriers.

Non-hospital residential facilities and services like detoxification are generally not covered by Medicare.

“As a result, many of our patients have limited access to residential care and have to seek out hospital-based programs when needing detoxification, which may be more intensive than what the patient needs,” Kelly said. “There are also fewer hospital-based programs with a limited number of beds, which further restricts access. What we really need is expanded Medicare coverage for residential services. There are also restrictions on which intensive outpatient programs patients can access, which further complicates care options for patients.”

Challenges in proving the need for comprehensive, continuity of care are also prevalent, Swift said, and Medicare tends to question repeated relapse and remittance services more than other insurers. However, any treatment gaps that currently exist or may exist as the landscape shifts can be resolved, Swift explained.

“I think that there won’t necessarily be treatment gaps if we can meet the need and understand that many of the interventions can be moved into the primary care setting,” Swift said. “We as a health care profession and a country could dive into the education and get buy-in from these primary care providers to collaborate with us to make sure that there are no gaps, even as things pull away [with funding and policy]. I do think that we could bridge that change, but it would be a collaboration we would have to have support with.”