Email UpdatesRegrettably, funding for primary care1 in general, and for treatment of OUD specifically,2 is not generous and is rarely considered to be adequate.3 That said, there are a diverse array of funding models.4 It is impossible to provide a single strategy to achieve financial sustainability given the widespread differences in payer policies for primary care and OUD treatment.4 Devising a strategy will require a careful review of your baseline financial status, patient mix, payer mix, and associated policies.
Because this is a complex set of issues, it may be wise to consider reaching out to an experienced practice facilitator who understands what care models and reimbursement options are available in your state and area. Some states have organized practice facilitation organizations designed specifically to help improve the operations and effectiveness of primary care providers. If no such organization is available in your state, consider consulting with similarly situated professional colleagues or professional associations. For example, your state primary care association5 (especially for FQHCs and community health clinics) or your state health agency6 may be helpful.
North Star
The practice implements a model for treatment of people with OUD that is sustainable within the limitations of the available resources and financial landscape.
Practices assess the financial landscape by identifying the relevant policies, processes, and requirements related to the delivery and reimbursement of services across public and private payers in their state.
To ensure financial sustainability, begin planning early, starting in the pre-implementation phase. Include a representative from the billing or revenue cycle team on the pre-implementation planning team, as financial factors can shape your choice of service model.42 Flexibility in your MOUD reimbursement strategy is often recommended. Ultimately, sustainability will depend on state reimbursement policies, your payer mix,4 available resources, infrastructure, and payment rates.
Identify your payer mix. Most primary care practices serve patients with different insurance coverage. Some of the payers may include:
- Medicare fee-for-service;
- Medicare Advantage plans;
- Medicaid fee-for-service;
- Medicaid managed care organizations;
- Private insurers; and
- Private pay.
Investigate the relevant policies of each of the payers for your patient mix and learn what and how much they will reimburse for necessary services and which staff members must provide them. Note that in some circumstances it may be necessary or preferable to create staff roles that will provide non-reimbursable services. For example, a patient engagement specialist or care coordinator may take on the responsibility of patient outreach and follow up but allow other providers to practice at the top of their license and spend more time billing for their services.
For uninsured patients with OUD, some states have programs that provide MOUD free of charge or sliding scale models for those who are uninsured. For example, in New Mexico this program is provided by the New Mexico Department of Health.7 In addition, grants such as the current SAMHSA State Opioid Response require that MOUD be provided regardless of the patient's ability to pay.8
When planning to provide medications for OUD, consider how to make it financially sustainable over time, including the stability of program funding sources. For example, grant funding can be vital toward an initial investment to start an OUD treatment practice, but it is temporary. It can be very helpful in covering costs associated with transitioning to an alternate service delivery model but cannot cover ongoing operational costs over time.
The configuration of a clinical and support team, salaries, overhead costs, and reimbursement rates are all important considerations. In addition, financial sustainability often depends on the scale of the practice, that is, the number of patients the practice will be treating. These sorts of analyses are based on program- and state- specific assumptions of personnel salaries and other programmatic expenses, as well as payers' reimbursement rates for services provided to patients served.
As you develop your office-based practice to treat OUD, you might want to develop your own financial sustainability model,9 similar to those from the Medicaid Innovation Accelerator Program | Medicaid that reflects salary, cost, and reimbursement data for your practice. You will need to work with your budgeting and financial staff to develop such models, in collaboration with clinical staff, so that models are designed to meet the needs of the patients served.
- Don't start implementing MOUD without considering the need for long-term financial stability. Developing a sustainability plan should be an early component of your MOUD work.
- Don't fail to explore alternative payment models (APMs) that may be available from the payers in your patient mix. APMs that reflect clinical requirements can sometimes be negotiated to better support the provision of medications for OUD.
- Don't miss the opportunity to be innovative in your clinical and staffing approach, building on the evidence base on what works for the kinds of patients you treat.
Substance Use Disorder Tools & Resources: National Learning Webinars & Resources
Boston Medical Center Office Based Addition Treatment Training and Technical Assistance
Patient-Centered Opioid Addiction Treatment (P-COAT) Alternative Payment Model
Module 5: Planning for Funding and Sustainability
This module discusses the key issues in planning for sustainability of health programs in rural communities.
Developing a Plan for Financial Sustainability
A section within the Community Tool Box that describes how to plan the financial stability of an organization or program.
Exploring Value-Based Payment for Substance Use Disorder Services in the United States
Exploring Value-Based Payment to Encourage Substance Use Disorder Treatment in Primary Care
Substance Use Screenings & Treatment
This document provides comprehensive guidelines on screening, treating, and billing for substance use disorders (SUDs).
A Prescriber's Guide to Medicare Prescription Drug (Part D) Opioid Policies
This document provides detailed guidelines on managing opioid prescriptions under Medicare Part D.
1. Jabbarpour Y. The Cost of Neglect: How Chronic Underinvestment in Primary Care Is Failing US Patients. Milbank Memorial Fund Accessed April 28, 2025. https://www.milbank.org/wp-content/uploads/2025/02/Milbank-Scorecard-2025-ACCESS-v07.pdf
2. Clemans-Cope L, Lynch V, Payton M, Aarons J. Medicaid professional fees for treatment of opioid use disorder varied widely across states and were substantially below fees paid by medicare in 2021. Substance Abuse Treatment, Prevention, and Policy. 2022;17(1):49. doi:10.1186/s13011-022-00478-y
3. McGinty EE, White SA, Eisenberg MD, Palmer NR, Brown CH, Saloner BK. US payment policy for medications to treat opioid use disorder: landscape and opportunities. Health Aff Sch. 2024;2(3):qxae024. doi:10.1093/haschl/qxae024
4. Hodgkin D, Horgan C, Bart G. Financial sustainability of payment models for office-based opioid treatment in outpatient clinics. Addict Sci Clin Pract. 2021;16(1):45. doi:10.1186/s13722-021-00253-7
5. National Association of Community Health Centers. Directory of PCAs & HCCNs. NACHC. 2025. Accessed April 28, 2025. https://www.nachc.org/state-regional-affiliates-networks/directory-of-pcas-hccns/
6. USAGov. State health departments. 2025. Accessed April 28, 2025. https://www.usa.gov/state-health
7. The New Mexico Health Care Authority. Medication-Assisted Treatment (MAT) | New Mexico | Help Available Statewide. Dose of Reality. Accessed May 30, 2025. https://www.doseofreality.com/about-treatment/
8. Substance Abuse and Mental Health Services Administration. FY 2024 State Opioid Response Grants Notice of Funding Opportunity. Published online 2024. Accessed May 30, 2025. https://www.samhsa.gov/sites/default/files/grants/pdf/fy-2024-sor-nofo.pdf#:~:text=Applications%20are%20due%20by%20July%201%2C%202024.%20Throughout,detailed%20instructions%20on%20preparing%20and%20submitting%20your%20application.
9. Center of Excellence for Integrated Health Solutions. Integrated Care Financing Series: Module 1. National Council for Mental Wellbeing; 2022. Accessed May 4, 2025. https://www.thenationalcouncil.org/wp-content/uploads/2025/02/CoE-Billing-Modules_MODULE-1_Revisions-22.12.12.pdf