With the Medicaid expansion and insurance exchanges of the Affordable Care Act (ACA) due to take effect January 1, 2014, and enrollment starting October 1, 2013, opioid treatment programs (OTPs) are gearing up for the expected increased demand for services. But they can’t expect patients to just show up—they need to make sure that they get referrals, particularly from primary care providers, insurance networks, and the criminal justice system. OTPs also need to be flexible with medications, using buprenorphine and naltrexone as well as methadone.
Each state is going to have different rules for the benefit package. AT Forum talked with Mark W. Parrino, MPA, president of the American Association for the Treatment of Opioid Dependence (AATOD), and Jerry Rhodes, chief operating officer for CRC Health Group, for insights into how OTPs can get ready for health care reform.
Medicaid and the States
OTPs should be working with the authorities in their respective states to increase access to Medicaid reimbursement, said Mr. Parrino. “This is a hard road to climb given the impediments that exist in the states in increasing access to Medicaid reimbursement.” In addition, many OTPs in the private for-profit sector are reluctant to move into the Medicaid arena, due to their current structure of accepting self-pay out-of-pocket payments, he said.
There is no overriding national initiative that an organization can take that will apply to all states, said Mr. Rhodes. “I think this is going to be largely a state by state thing.” CRC, which has OTPs in many states, knows this well. For example, in a move that has alarmed OTPs, California, which has embraced Medicaid expansion and the health insurance exchanges, has selected a benchmark small business plan which does not cover methadone maintenance at all, only buprenorphine.
And while that California benchmark plan is the most recent overt example of discrimination against methadone, it’s an old story in many states, said Mr. Rhodes. In 17 states there is no Medicaid coverage at all for methadone maintenance; patients must pay out of their own pockets. “We see this consistently in some states we operate in,” said Mr. Rhodes. The most severe example now is Maine, but the same issue has been ongoing in West Virginia. (Note: CRC does not operate in Maine, but does in West Virginia.)
In general, states that have made commitments to supporting methadone are the same states that are participating in the expansion of the Medicaid population, with the exception of California. “But it’s going to get into the politics of the states,” said Mr. Rhodes. Maine, which did have a strong OTP presence, saw restrictions begin when a new governor was elected. “It’s a manifestation of the broader problem politically with the perceptions of methadone,” said Mr. Rhodes. “Methadone elicits controversy, and seems to find few friends.”
This controversy has added an extra layer of uncertainty to how OTPs will respond to the ACA.
Using new medications—buprenorphine and naloxone (oral and extended release)—will be key to the OTP response to increased demand, said Mr. Parrino. That’s why he was pressing the Substance Abuse and Mental Health Services Administration (SAMHSA) to approve the Federal Register notice allowing OTPs to dispense buprenorphine, he told AT Forum. The notice, published December 6, 2012, paved the way for OTPs to use another medication, in addition to methadone. In addition, AATOD published guidelines recommending the use of Vivitrol, as well.
OTPs will also be able to use naltrexone/Vivitrol, which has none of the restrictions of buprenorphine or methadone, since it is not an opioid agonist. Vivitrol is expected to be requested by criminal justice clients, and OTPs will be working to a greater degree with this population, said Mr. Parrino. “In this way, OTPs should be using all three federally approved medications to treat chronic opioid addiction.”
It will also be easier for OTPs to expand their staff under the recent draft accreditation guidelines from SAMHSA (see related article in this issue), which reflect the changing dynamics of health care under the ACA. In particular, the guidelines support mid-level practitioners—nurse practitioners and physician assistants—in OTPs. “This was a long road for SAMHSA but I believe that they understand that having physicians at the OTPs will be more difficult,” Mr. Parrino said. Physicians will also be facing increased demand across the country for all kinds of health care as more people have insurance.
While OTPs have been treating a large number of patients who are dependent on prescription opioids—a phenomenon that Mr. Parrino does not expect to change soon—he also thinks that there is a need to connect with drug courts and mental health programs to set up collaborative treatment arrangements.
Like all health care facilities, OTPs have to face the reality of physical limitations, which makes it difficult to have unlimited expansion. However, OTPs have the advantage of being 100-percent outpatient, which should provide “breathing room” in terms of treatment expansion, said Mr. Parrino.
AATOD encourages OTPs to develop letters of agreement with other health care providers in their geographic areas in order to increase referrals.
For patients who are covered by private insurance, either on the exchanges or not, it may be easier to obtain reimbursement, said Mr. Rhodes. “Unlike Medicaid, the private market will offer opportunities to OTPs.” But this will be highly selective, depending on how the state designs the benefits. CRC has seen an expansion of commercial payers to methadone already.
For OTPs unused to working with insurance, it’s a good idea to start a dialogue now, said Mr. Rhodes. “Start the process of applying to be a provider,” he said. “This can be a lengthy process.”
So far, most OTPs working with Medicaid have been operating under managed care, but not sharing risk. Ultimately, there will be more of that in the future—in which the OTP gets paid a set fee per member per month, and must deliver all needed OTP services for all members for that set amount. “I don’t see any immediate push to drive us into risk sharing,” said Mr. Rhodes. “But ultimately I can see the system going in that direction. The bellwether will be what is happening on the acute general side, where there isn’t any wholesale risk-sharing now.”
Both officials recommended that OTPs be prepared to evolve quickly. “In the end, there will be winners and loser,” said Mr. Rhodes.