Some states are making opioid treatment programs (OTPs) health homes under a federal strategy that is part of the Affordable Care Act (ACA). Under the initiative, which comes from the Centers for Medicare and Medicaid Services (CMS), states can pay OTPs extra money to serve as “health homes” for their patients, meaning that the OTPs will help clients manage both their physical and behavioral health needs, including chronic conditions like obesity and diabetes.
So far, only Maryland, Rhode Island, and Vermont are paying OTPs to be health homes under the ACA. AT Forum talked with health home leaders in the first two states.
“This is a CMS strategy and an endeavor that we support,” said H. Westley Clark, MD, JD, director of the Center for Substance Abuse Treatment at the Substance Abuse and Mental Health Services Administration (SAMHSA). “From our point of view, we believe the ACA is an important vehicle for behavioral health, and that includes OTPs.”
For OTPs to play an enhanced role under the ACA, states need to apply for approval from CMS to allow the OTPs to serve as health homes, and must use Medicaid money for this purpose.
“The states that have included OTPs in the state plan amendments are doing the field a favor,” said Dr. Clark. He added that this is a critical step, as OTPs try to become participants in the new reimbursement framework.
The state Medicaid dollars that will be going to OTP health homes will initially be matched 90 percent by the federal government.
The logic of selecting OTPs to be health homes, among all substance abuse treatment providers, is that OTPs already have medical staff. OTP patients have a range of conditions that medical staff can address, Dr. Clark said.
SAMHSA has strongly promoted the need for OTPs to have electronic health records, qualified service organization agreements, and health homes, “so OTPs can play a stronger role” under the ACA. CMS is the lead agency on the ACA, with SAMHSA on the periphery, Dr. Clark explained. “Since this is a nascent activity, our role has not been robust. But we are talking to the American Association for the Treatment of Opioid Dependence (AATOD) and to OTPs about the ACA and our hope that OTPs will play a larger role in the delivery of services.”
There’s a big difference between a “patient-centered medical home,” which is a very broad term, and a “health home,” which is codified in the ACA. A health home is for individuals with a chronic condition; importantly, a substance use disorder (SUD) is included in the definition of a chronic condition. A patient-centered medical home is a primary care approach in which there is a home base for both healthy and unhealthy people.
To participate in a behavioral health care health home under the ACA, and to qualify for the 90-percent federal match, the patient must either have a serious and persistent mental illness and two chronic conditions, or have one chronic condition and be at risk for another. In other words, patients with an SUD and at risk for another chronic condition would be eligible, and this constitutes almost all patients in OTPs.
Rhode Island was still waiting to hear back from CMS on its state plan amendment, which created health homes in OTPs, when AT Forum interviewed Rebecca L. Boss, administrator of behavioral health services in the state’s Department of Behavioral Healthcare, Developmental Disabilities, and Hospitals. But because the CMS decision can be retroactive—and approval of the proposal was expected—the state is going ahead with implementing health homes at five of the state’s six OTPs.
Ms. Boss, who is also the State Opioid Treatment Authority (SOTA) for Rhode Island, said having OTPs be health homes is a “passion” for her. “Having worked in an OTP, I know first-hand that patients in opioid treatment who have chronic conditions have had difficulty accessing quality medical care,” she told AT Forum. “What better place, in my mind, than an OTP where patients have relationships with medical staff, where they’re comfortable, and where they show up on a regular basis.”
Barriers to health care for OTP patients have included stigma, transportation problems, and lack of insurance, noted Ms. Boss, who added that some patients just need help following up on treatment plans, such as taking medication for diabetes.
A small state, Rhode Island has 3,800 OTP patients receiving methadone maintenance treatment on any given day. About 2,000 are current Medicaid clients—a number that will grow on January 1 when Medicaid expands.
$87 per Patient per Week
There will be 125 patients in each OTP “health home” team, with at least 10 teams statewide, Ms. Boss said. OTPs will get about $87 per week for each patient in a health home team. This rate is separate and apart from what OTPs receive for treatment and an important part of rate setting was teasing out which services covered under treatment would be considered health home activities. Ms. Boss added that the federal government pays 90 percent of the health home service part for the first two years.
Factors such as tobacco use, obesity, and increased age can count as risk for development of a second chronic condition, in addition to SUDs, according to Ms. Boss. “It would be rare that clients in an OTP not meet the criteria” for being in a health home.
One of the biggest challenges will be recruiting patients for health homes. Enrollment has to be voluntary. In Rhode Island, individuals have been auto-enrolled, but have the right to opt out, Ms. Boss explained.
OTPs don’t need to provide health care services to be health homes, but they do need to make sure patients have access to such services. In Rhode Island, there will be a nurse dedicated to following 125 patients, coordinating their care. “Patients don’t have to go to just any nurse at a dosing window, they have their own nurse who will help them,” said Ms. Boss.
In many cases, OTPs have already been helping patients who have health issues. “This is the opportunity to reimburse them for some services they have been doing all along,” according to Ms. Boss. “They haven’t had a lot of case managers, but counselors have been doing yeoman’s work in terms of case management.” She added that the health home fees will also pay for part of a physician’s time, the services of case managers, the coordinating services of a masters-level team, and a pharmacist to coordinate medications.
Maryland has identified three provider types to be health homes—two are mental health, and one is an OTP. To be eligible as a health home, an OTP must be enrolled with Maryland Medicaid, be accredited by CARF International or the Joint Commission (or pursuing such accreditation), and submit an application to the state. As of November 4, eight OTPs have submitted applications and three have been approved.
According to Lisa Hadley, MD, clinical director of the state’s Alcohol and Drug Abuse Administration and Mental Hygiene Administration, participants must have an SUD, be in methadone treatment, and be at risk for another chronic condition—similar to the Rhode Island health home initiative. For the three OTPs approved so far, there are almost 1,000 patients—410 in one OTP, 281 in another, and 285 in the third.
Almost $99 per Patient per Month
Maryland health home OTPs will be paid an additional $98.87 a month for each patient in the health home, said Dr. Hadley, who is also the SOTA for Maryland. The OTPs will be responsible for providing six different services: comprehensive care management, care coordination, health promotion, individual and family support, and referrals for community support. “Through all their treatment, whether they’re in the hospital or in the community, the health home is responsible for helping to link the patient to what they need.” According to Dr. Hadley, Maryland Medicaid will pay the additional fee, with the federal government paying 90 percent for the first two years, after which the match goes down to the standard 50 percent.
The state will also help the OTPs by providing data on hospital encounters and pharmacy alerts, she said. The program started in October, and is expected to grow in January. “We hope to be getting more applications” from OTPs. “We’re very excited to be able to help OTP patients.”