Proposal to Increase Medicaid Utilization for OTPs

Overview/Project Objectives
The primary objective of this project is to increase access to the treatment of opioid addiction through Opioid Treatment Programs (OTPs), focusing on the 17-19 states, which do not provide Medicaid reimbursement for the treatment of opioid addicted patients through OTPs. We have learned through recently published research from Johns Hopkins that there is a 25% increase in service utilization in OTPs when Medicaid reimbursement is provided to OTPs.

A secondary result in increasing access to Medicaid reimbursement in OTPs in the identified states may also generate new OTPs sites in order to treat a new population of patients, who have not accessed care for lack of funds.

At the present time, there are approximately 1,300 Opioid Treatment Programs (OTPs) treating approximately 340,000 – 350,000 patients on any given day in 48 states. More than 50% of these OTPs are proprietary. Over the course of the past ten years, the major expansion of OTPs has come through the proprietary sector either through acquisition of existing OTPs or the development of new facilities.

There are also state policies which either work for or against OTPs. On the positive side, North Dakota has been working to site the first OTPs in their state. There are several providers who have submitted applications to open these programs, and they are now working through the challenges of several municipalities with regard to moratoria in opening proposed sites. It is anticipated that they will surmount this challenge and that OTPs are likely to open either in the last quarter of this calendar year or the first quarter of 2016.

On the negative side of state challenges, Governor LePage and his administration in Maine have been working to close OTPs. This would affect the lives of more than 3,500 patients. Governor LePage has devoted his administration to ending the availability of methadone treatment through OTPs in the state for a number of reasons. He seems to prefer Vivitrol/Naltrexone and he also is of the judgment that all of the methadone maintained patients in the OTPs can be transitioned to buprenorphine. We have advised his administration that this is not the case, and fortunately the state legislature in Maine seems to agree with AATOD’s point of view.

Working with Federal Agencies
AATOD has been working with the relevant federal agencies to provide Medicaid reimbursement to OTPs in treating Medicaid beneficiaries over the course of the last several months. Secretary Burwell of the Department of Health and Human Services convened a meeting with AATOD and its constituent groups during February 2015. The Secretary has made it clear that one of her major goals with the Department is to increase access to Medication Assisted Treatment for opioid addiction, including OTPs. The Department is also working with its relevant sub agencies, the Substance Abuse and Mental Health Services Administration (SAMHSA) and the White House Office of National Drug Control Policy (ONDCP), to better coordinate increasing access to Medication Assisted Treatment, in OTPs, DATA 2000 practices, and Federally Qualified Health Centers (FQHC). In fact, the Department has just made 100 million dollars available to increase MAT for opioid addiction through designated FQHCs.

We have identified 17-19 states that currently do not provide Medicaid reimbursement for the use of medications and other services in OTPs when they are treating Medicaid beneficiaries. In such states, the only way that such beneficiaries can access treatment if they are able to make out of pocket payments. Such payments become the financial model for the treatment of most patients in these states. I am attaching my communication to Madlyn Kruh of CMS/Medicaid, which provides a listing of these states. I have also been working with the AATOD Board of Directors, which represents 29 state chapters in the US and in Mexico. In this case, the AATOD Board and its state member chapters represent over 1,000 OTPs.

Ms. Kruh and her associates at CMS/Medicaid have been helpful in working with AATOD to help remove the impediment of Medicaid reimbursement not providing coverage for their beneficiaries in OTPs, as indicated above. Unlike Medicare coverage, which is still spotty for OTPs, the Medicaid issue is more complex since the states need to be willing partners in providing such reimbursement. Accordingly, if the state does not have an interest in providing Medicaid coverage for the use of medications and services in OTPs, the federal authorities including the Department and all of its relevant sub agencies cannot compel the states to do this.

Working with AATOD’s Policy Partners
I have also been discussing this matter with AATOD’s counterparts at the National Association of State Alcohol and Drug Abuse Directors (NASADAD) and have indicated the critical role that their State Alcohol and Drug Abuse Directors will play in the identified states. In this particular case, the opioid treatment providers in one of the effected states, principally the OTPs, would meet with the State Alcohol and Drug Abuse Director. This would be the first stage in getting consensus on having the State Alcohol and Drug Abuse Director support the interests of the OTPs to work with the appropriate State Medicaid Rate Setting Authority. Typically, the State Medicaid Authorities do not meet with their counterparts in the State Alcohol and Drug Abuse divisions. There are obvious exceptions to this organizing point, but this is typically the case. Very rarely do OTPs meet with the State Medicaid Rate Setting Authorities on their own.

In this policymaking scenario, the OTPs would first meet with the State Alcohol and Drug Abuse Director and that director would arrange a meeting with the designated Medicaid Rate Setting Authority in the state. Once all three parties have met and agreed on a strategic approach to provide Medicaid reimbursement for OTP services, the State Medicaid Rate Setting Authority will go through the process of submitting a state plan amendment to CMS/Medicaid.

AATOD has also had discussions with its policy partners at the Legal Action Center in view of the expertise that Legal Action Center representatives have demonstrated in co-founding the Coalition for Whole Health and working through all of the complexities of the Affordable Care Act and Parity legislation. The Legal Action Center will provide consultation to the states that have an interest in removing the Medicaid reimbursement impediments which stand in the way of increasing access to care.

I have also discussed this strategy with representatives to the Department of Health and Human Services and I am enclosing my recent communication to Dr. Richard Frank, who serves as the Under Secretary in the Department for Strategic Planning. They support this policy initiative since it reflects Secretary Burwell’s interest in increasing access to Medication Assisted Treatment for opioid addiction. In my many years in working with all of the federal agencies, the Secretary’s support is critical, which also explains why CMS/Medicaid representatives are interested in working with AATOD and its policy partners to resolve this issue.

This proposal is based on how states have approached Medicaid for services provided to patients through OTPs. Most of the AATOD member states have such reimbursement mechanisms in place. Obviously, the Medicaid reimbursement changes from one state to another. Some Medicaid rate setting authorities have established weekly bundled rates to provide reimbursement for medication and a listing of designated services, which are all provided through the OTP. Some states provide more of an “al a carte” fee for service arrangement, providing separate Medicaid reimbursement for the use and administration of medications, the use of toxicology and lab testing, and the development and provision of individual and/or group counseling services.

We have already had some preliminary success with this approach in Georgia. Our Georgia provider colleagues formed a unified position in order to meet with the State Alcohol and Drug Abuse Authority in developing a reimbursement mechanism for its Medicaid beneficiaries. They have recently met with these authorities and have indicated that they are interested in establishing this Medicaid reimbursement mechanism.

AATOD will work with all of the parties indicated above in each of the states that do not provide any Medicaid reimbursement for MAT in the OTP setting. It is understood that this will be a state by state initiative with the support of policy partners such as NASADAD and the Legal Action Center, in addition to the Department of Health and Human Services and its sub agencies, including SAMHSA.

Once the states have agreed to support Medicaid reimbursement for services in OTPs, and once the Medicaid Rate Setting Authority forwards a Medicaid State Plan Amendment to CMS/Medicaid, AATOD will work to advocate that CMS/Medicaid and other relevant agencies will provide all necessary technical assistance to the state in getting their State Plan Amendment approved in addition to having SAMHSA provide whatever technical assistance is necessary to the providers to get them on board with such reimbursement mechanisms in cooperation with the designated State Alcohol and Drug Abuse Authority.

This is an extremely complex undertaking and requires cooperation with a number of parties in order to be successful. We already have preliminary information which compares states that provide Medicaid to OTPs in treating Medicaid beneficiaries with states that do not. According to researchers at Johns Hopkins, the states that provide Medicaid reimbursement for Medicaid beneficiaries in OTPs have a 25% higher utilization of those services in such states. While this is not a surprise to anyone, it represents an extraordinary and newly documented finding. An article will be published very shortly in a peer review journal and that article will be shared with all of the Medicaid Rate Setting Authorities and State Alcohol and Drug Abuse Directors in the affected states, as well as all of the appropriate federal agencies within the structure of the Department of Health and Human Services and their policy partners at the White House Office of National Drug Control Policy.

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