A year ago, the Affordable Care Act (ACA), with the expansion of Medicaid and the inclusion of private insurance subsidies, took effect. In the states that expanded Medicaid, this has been a boon to opioid treatment program (OTP) patients, in some cases, but not all. And in the states that didn’t, it hasn’t. And even in the states that enthusiastically endorsed the ACA, private insurance carriers have been slow to get on board, AT Forum has learned.
“The issue of how OTPs are responding to health care reform clearly depends on the state the OTP is in,” said Mark Parrino, MPA, president of the American Association for the Treatment of Opioid Dependence (AATOD).
In addition to Mr. Parrino for a national overview, AT Forum interviewed representatives in three states about how the ACA has affected OTPs. The biggest problems are in states that didn’t expand Medicaid, such as Georgia.
OTPs in Georgia “continue to face a lack of support for having any reimbursement for their services, no matter what the medication,” said Mr. Parrino.
“The main stumbling block for many of the providers is the requirement that the clinic become a Core Provider,” explained Stacey Pearce, BS, CAS, president and program director of GPA Treatment of Macon, Inc. To become a “Core Provider” in Georgia, an OTP would have to employ a full-time physician. “For many of the clinics in Georgia it would be fiscally irresponsible to try to meet this criterion,” she said, noting that she, a certified addiction specialist, has about 100 patients. That number does not support the ability to pay a full-time physician, said Ms. Pearce, who is the delegate to AATOD from the Opioid Treatment Providers of Georgia.
Overall, she said, the ACA hasn’t changed anything for patients in Georgia, possibly in part because of the lack of Medicaid expansion.
In New York State there’s a very different, specific problem: getting the program to pay for buprenorphine. Previously, the state was the only one that had a Medicaid rate for buprenorphine, but all that changed when the system went to the APG (Ambulatory Patient Group) reimbursement rates, explained Allegra Schorr, president of the Committee of Methadone Program Administrators (COMPA) of New York. Ms. Schorr’s patients who were receiving buprenorphine under the pre-APG system kept their services, but the program couldn’t expand.
Increasing the number of patients in an OTP on buprenorphine is a good way to expand access to treatment: while office-based physicians are limited to 100 patients on buprenorphine, there is no such cap for OTPs. So it’s unfortunate that there is no reimbursement rate ready for OTPs in New York.
“At one point I had quite a few patients trying to access care” with buprenorphine, said Ms. Schorr, who is also vice president and owner of West Midtown Medical Group, an OTP in New York City. Soon, however, she wasn’t able to offer buprenorphine at all, because Reckitt Benckiser, which was the only supplier at the time, raised its minimum order to such a large amount that it couldn’t even fit in the safe. “We went from a waiting list to not being able to offer it at all,” recalls Ms. Schorr. Of course, this was several years ago when Reckitt Benckiser had a monopoly on buprenorphine; and before the federal Substance Abuse and Mental Health Services Administration adjusted the regulations on buprenorphine in OTPs.
Patients in OTPs get other medications in addition to methadone and buprenorphine─why not just pay for them the same way medications are covered in the Medicaid program in general? The problem is that the promulgated rate for buprenorphine is too complicated to use, so providers don’t use it. Although the Department of Health understands that OTPs aren’t pharmacies, reimbursement for buprenorphine would require the complicated coding system used by pharmacies, said Ms. Schorr, who recently took over as COMPA president from Henry Bartlett, who had been leading these negotiations. Last fall he joined Alkermes, where he is New York State representative for Vivitrol.
The most recent discussion between COMPA and the Department of Health, which runs the state’s Medicaid program, was productive, said Ms. Schorr, “but we’re not there yet.” Once the state understood that OTPs can’t afford to buy buprenorphine out of their APG rate, officials said they would explore options. Of course, officials (Rob Kent, Pat Lincourt, and the State Opioid Treatment Authority [SOTA], Belinda Greenfield, PhD, from the state’s Office of Alcoholism and Substance Abuse Services, which has the legend “Combat Heroin and Prescription Drug Abuse” imposed upon a graphic of the state on its website, did go to bat for the OTPs. “My sense is that they do want to see increased access to medications,” she said.
Further complicating the issue in New York is the so-called Medicaid transformation, which is actually a major shift from fee-for-service to managed care for substance use disorders. During that transition, the current APG rates will remain in effect for two years. COMPA has asked that OTPs be considered essential providers and included in every contract, with no OTP left out of any panel. COMPA has also asked that the placement criteria be mandated by the state and be transparent. “We don’t want an insurance company to say who is eligible for treatment and who isn’t,” said Ms. Schorr.
The state has agreed to these requests, but only for two years. The clock hasn’t started yet, but when it does, the two-year period should give OTPs time for a “soft landing” under health care reform.
Contracts start in April, which is now looking “very soon,” said Ms. Schorr. “We have an agreement with OASAS to have small meetings with health care plans, vendors, information technology people, and our programs.” For commercial insurance companies, an OTP is a completely new entity, so an educational period is essential. Unlike Medicaid, commercial plans have never covered OTPs. Under Obamacare, they have to─at least in the states that call OTPs essential providers, like New York.
“One breakdown in communication has been in understanding that, even in hospital-based programs, OTPs are not pharmacies,” said Ms. Schorr. “We are treatment programs. We need a rate that allows us to treat patients, that is compliant with our confidentiality regulations, that expands access to care. And we need it quickly before we lose more patients to this epidemic.”
The learning curve on OTPs is huge for commercial plans and OTPs, agreed Jason Kletter, PhD, president of Bay Area Addiction Research and Treatment (BAART) programs. For Medicaid beneficiaries with opioid use disorders, however, health care reform has been “really, really good” for gaining access to treatment for opioid- dependent people, he said. “We’re fortunate in California because the state was an early adopter of Medicaid expansion.” BAART hired people, got them certified as enrollment specialists, and enrolled patients not previously eligible for Medicaid. “They went from struggling to pay out-of-pocket to having health insurance that covered the cost of their care,” he said. “In that respect, it’s been great.”
On the commercial side, in terms of patients who get health insurance through their employer or on the exchange, there has been what Dr. Kletter terms “some progress.” Again, unlike Medicaid, insurance companies had little understanding of OTPs. Some insurance companies, such as Kaiser Permanente, Blue Cross, and Magellan, acknowledged their new obligations to have a network for medication-assisted treatment, said Dr. Kletter, who is also president of the California Opioid Maintenance Providers (COMP). “We entered into some contracts,” he said. But there are very few patients accessing services through those plans.
However, it’s progress that commercial plans are even including OTP as a benefit, said Dr. Kletter. “In principle, the companies are agreeing to the bundled package” that constitutes an OTP─it’s not just medication. “It’s clear that they didn’t really understand our service at all, at the beginning. “It takes time to educate them, but in concept they’re coming along.”
When BAART was enrolling patients, it enrolled non-patients in the process─people who weren’t even in OTPs came in off the street to get enrolled in Medicaid, he said. That was fine with him. “The takeaway is that health care reform has been a huge success for folks in California, due to Medicaid expansion. “We’re making strides in our relationships with private managed care organizations, and over time we’ll get more and more of those patients into treatment.
Medicaid expansion in states that embraced the ACA has clearly been a success for OTPs and patients. But whether it’s buprenorphine reimbursement or problems with commercial insurance, health care reform has not solved many of the issues, something that the federal Centers for Medicare and Medicaid Services (CMS) and the Substance Abuse and Mental Health Services Administration (SAMHSA) are aware of, according to Mr. Parrino. “I have advised the CMS and SAMHSA that the major impediment to the use of buprenorphine in OTPs is the lack of third party insurance reimbursement,” he told AT Forum. “I have also reminded them that of the 48 states that have OTPs, 17 do not provide any reimbursement for any of the approved medications to treat opioid addiction.”
“We continue to make progress with increasing access, quality and affordability through ACA and parity rules,” CMS’ John O’Brien told AT Forum in an email sent via the press office of the Department of Health and Human Services. “Clearly there are barriers that remain and that’s why we keep working with OTPs, states and others to increase access to medication-assisted treatment.”
But from a national perspective, the ACA did not fulfill the promise it made, said Mr. Parrino. “From my point of view, health care reform has not had any tremendous impact in changing how patients are admitted to OTPS, or any immediate measurable impact on increased access to OTPs,” he said. “There are exceptions, such as California, which has opted for Medicaid expansion; but on the other hand, there are states such as Maine which are providing substandard Medicaid reimbursement rates for OTPs.”