Providing Buprenorphine in an Opioid Treatment Program: Challenges and Opportunities

shutterstock_3917107When the federal government said in December of 2012 that opioid treatment programs (OTPs) can dispense take-home doses of buprenorphine with fewer restrictions than are placed on take-home doses for methadone—in particular, no waiting period (http://atforum.com/news/2013/02/otps-can-now-dispense-buprenorphine-take-homes-with-no-waiting-periods/), there was an expectation that patients and treatment providers would be interested in buprenorphine. But there was also a concern that the high cost of buprenorphine compared to methadone would be an obstacle. In addition, states have their own rules that may be stricter than the federal government’s.

It turns out that more than a year later, most OTPs are still not dispensing buprenorphine on a widespread basis, and the main reasons are cost and insurance reimbursement. “I just completed a survey among the State Opioid Treatment Authorities, to find out what they think the impediments are to the use of buprenorphine in their state,” Mark Parrino, MPA, President of the American Association for the Treatment of Opioid Dependence (AATOD), told AT Forum in April. “It would seem that the biggest singular impediment is the lack of insurance reimbursement in OTPs.

“California and New York are states with the largest number of certified OTPs; however, California Medicaid does not provide any reimbursement for buprenorphine use in OTPs. At the present time, New York State does not have a current Medicaid reimbursement mechanism for buprenorphine use in their OTPs, although it did have such a reimbursement before the state converted to a new system called APGs [Ambulatory Patient Groups]. I understand that state officials and treatment providers, as organized through COMPA [Committee of Methadone Program Administrators of New York State, Inc.] are working to correct the problem.“

Other states have legislative restrictions for the use of public funds to use buprenorphine in OTPs. Idaho provides a case in point. North Dakota has just released its administrative/licensing regulations for OTPs, and the use of buprenorphine will be required in newly sited OTPs.

Here’s the problem. If buprenorphine is picked up in a pharmacy, the pharmacy benefit covers it. But if it’s dispensed by an OTP, there is no separate reimbursement for the medication—the cost has to come out of the fee the OTP gets for overall treatment. The cost of methadone is far less than the cost of buprenorphine, depending on the formulation.

Private insurance generally doesn’t cover OTP treatment services, in general, so the bulk of the payment falls on Medicaid or on self-pay patients. While there are 49 states that now allow OTPs, only 33 of them allow Medicaid to pay for such treatment, said Mr. Parrino. In the other states, patients have to make out-of-pocket payments. We have also learned that commercial insurance is providing coverage for OTP services but there are a number of restrictions when it comes to paying a claim.

“It’s a state-by-state fight,” he said. “There is no federal fix for this. There are states that have buprenorphine-only OTPs. Ohio provides an illustration where three buprenorphine-only OTPs were approved in 2013. Other states have reported this as well.”

Of course, the federal Centers for Medicare and Medicaid Services (CMS) would not block states that wanted to reimburse OTPs for dispensing buprenorphine, but CMS has historically not intervened if a state refuses to do so.

In some states, there are still regulatory, bureaucratic barriers that need to be fixed. For example, in many states, before the reimbursement issue can even be addressed, language changes are needed that would allow buprenorphine to be dispensed in an OTP.

In self-pay states, adding the cost of buprenorphine to what patients are already paying would be prohibitive, said Mr. Parrino. In spite of this, some treatment systems such as CRC have indicated that 10 percent of their patient population is currently utilizing buprenorphine through their network of OTPs.

When the rule allowing buprenorphine dispensing was published, Mr. Parrino immediately suggested to states that they look into actions that would encourage the use of buprenorphine. However, he doesn’t think there is necessarily great interest in patients switching from methadone to buprenorphine. “I haven’t heard of any groundswell of patients in an OTP saying ‘Please put me on buprenorphine so I can qualify for take-homes,’” he said.

There’s a lot that isn’t known, especially about the physicians who are prescribing buprenorphine from their offices. “We don’t know how many physicians are monitoring and tracking their patients,” said Mr. Parrino, noting that such monitoring and tracking is done by OTPs through federal and state regulations. But intuitively, he said, it makes some sense that a patient would rather go to an office-based treatment—regardless of whether the medication were methadone (which isn’t allowed to be dispensed or prescribed from an office), or buprenorphine—than to an OTP. “If I’m a patient who can pay for care, do I want to go to an OTP where there’s counseling requirements and toxicology testing, or to a physician where there aren’t any treatment requirements?” he asked rhetorically. “On the other hand, I have been informed that some patients do want such services and access such care through OTPs. It is also important to keep in mind that a number of physicians who have DATA 2000 practices are providing excellent care to patients as well as providing a comprehensive array of services at or through their offices. We just do not have credible data to indicate who is doing what.”

There are approximately 325,000 patients in OTPs at the present time. While it’s not clear how many patients are in ongoing treatment with buprenorphine from office-based physicians, AATOD estimates the number to be between 400,000 and 500,000.The number is based on prescriptions being written, but not necessarily unique patients, said Mr. Parrino.

In Vermont, where more OTPs are opening up, there is a current perceived advantage of having patients medicated on site, even with buprenorphine, because of diversion related issues.

New Jersey

We talked with Ed Higgins, MA, executive director and CEO of JSAS Healthcare Services, an OTP based in Neptune, New Jersey, and the only non-profit OTP in two contiguous counties. The insurance reimbursement problem is a reality, he said. When buprenorphine first came on the market, as Suboxone and Subutex, OTPs made sure it would be covered by Medicaid. And it is—but only as a pharmacy benefit. “I’m not a pharmacy,” said Mr. Higgins. “A Medicaid Rx card won’t work here.” The retail price for a 1-week supply of only 8 milligrams a day of buprenorphine is $50.

So at JSAS, all three physicians are waivered to prescribe buprenorphine. Two of them are American Society of Addiction Medicine (ASAM) physicians. They see patients and write a prescription for buprenorphine, most of which is not reimbursed, said Mr. Higgins. “We can’t bill extra for the induction,” he added. “It’s just a regular Medicaid office visit, and we’re working on 1985 rates.” Only one of our ASAM physicians is currently accepting self-pay patients.

Patients can get buprenorphine from other waived physicians, of course, but Mr. Higgins describes this as the “Wild West,” where patients are charged as much as $350 to $500 for the induction.

Mr. Higgins agrees that the cost of buprenorphine is prohibitive for self-pay patients. And he is curious about the “hundreds of thousands” of patients who enroll in the private-practice model of buprenorphine treatment each year. “This begs for a follow-up study,” he said. “How many of those patients stay in treatment?” There are also questions about dosing: the limit was supposed to be 16 milligrams a day, but there are some patients who require 24 milligrams—although not in his clinic—said Mr. Higgins. “That’s the reality in the private sector.” Some managed care companies are now mandating that patients on buprenorphine be given at least one counseling session a month, he said, while others have no counseling requirement.

Finally, Mr. Higgins said that there are patients who feel better on methadone. But they can’t have the freedom of going to private practitioners, and also be on methadone.

Fewer than 5 percent of the patients at JSAS are on buprenorphine, said Mr. Higgins. “In the world I’d like to live in, we would look at a patient, especially a younger patient, and say, ‘We have some choices for you.’” The OTP could recommend buprenorphine first, and if it doesn’t work, then easily convert to methadone. The problem is that the prices are still too high. There are now five generic forms of buprenorphine, and Mr. Higgins would like to see the manufacturers get together and lower the prices dramatically. “I’m not talking about 10 percent,” he said.

Now, however, the choices just come down to finance. “I can give you 80 milligrams of methadone, and my lowest cost for that is 36 cents. Or you can get a prescription for    16 milligrams of buprenorphine, which is a therapeutic dose, and your weekly cost is going to be approximately $100.”

JSAS gets $120 per month per patient from Medicaid.

 

 

 

States That Don’t Expand Medicaid Leave Millions of Mentally Ill Uninsured: Report

“About 3.7 million Americans, who live in states that have not expanded their Medicaid programs under the Affordable Care Act, suffer from mental illness, psychological distress or a substance use disorder and don’t have health insurance, according to a recent report.

Twenty-four states have not expanded their Medicaid programs, according to USA Today. In the states that did expand Medicaid, about 3 million people with a mental health or substance use disorder, who were formerly uninsured, now are eligible for coverage. The findings come from the American Mental Health Counselors Association (AMHCA).”

http://www.drugfree.org/join-together/community-related/states-that-dont-expand-medicaid-leave-millions-of-mentally-ill-uninsured

Source: JoinTogether.org – April 9, 2014

Medicaid Cutbacks in Maine Leave 400 OTP Patients without Coverage

medicaid“In what appears to be insult added to injury, Maine opioid treatment program (OTP) patients not only face having to prove themselves in order to stay in treatment for more than medicaidtwo years, but, due to a cutback in Medicaid, 400 of them will be left with no access to state-paid treatment no matter how well they are doing.”

Alcoholism Drug Abuse Weekly asked John A. Martins, spokesman for the Maine Department of Health and Human Services, in an e-mail what the state’s plans are for those patients.

“Substance use and abuse is not new in Maine or across the nation and occurred long before Maine’s initial expansion of the MaineCare program in 2002 to cover those who are losing coverage,” said Martins. “We remain committed to effective and efficient use of non-MaineCare resources to improve education and successfully prevent addiction and intervene early before addiction occurs.

http://www.alcoholismdrugabuseweekly.com/m-article-detail/medicaid-cutbacks-in-maine-leave-400-otp-patients-without-coverage.aspx

Source: AlcoholismDrugAbuseWeekly.com – January 27, 2014

Blog: What Health Care Reform Could Mean for Drug Policy and Mass Incarceration

healthcare reform 2“What does the Affordable Care Act (ACA) mean for drug policy?. A new issue brief – From Handcuffs to Healthcare — published by the Drug Policy Alliance (DPA) and the American Civil Liberties Union(ACLU) outlines how the ACA could help our country end the war on drugs and move toward a health-based approach to drug policy

This paper is intended as a starting framework for criminal justice and drug policy advocates to navigate the ACA, and to take advantage of the conceptual and practical opportunities it offers shifting the conversation and the landscape.

Part One of this paper describes some of the major provisions of the ACA relevant to our work: the health insurance requirement; the places many people will buy insurance, called health exchanges; Medicaid expansion; insurance coverage requirements for substance use and mental health disorders; and opportunities for improved models of coordinated care.

Part Two of this paper outlines a series of practical recommendations, including program and policy examples and suggested action steps, across three broad categories:

  • Ensuring access to care for people most likely to be steered into the criminal justice system under the current framework
  • Leveraging the ACA to reduce incarceration and criminal justice involvement
  •  Moving from a criminalization-based drug policy approach to one rooted in health

The Brief can be accessed at: http://www.drugpolicy.org/sites/default/files/Healthcare_Not_Handcuffs_12.17.pdf

Source: HuffingtonPost.com - December 3, 2013 and DrugPolicy.org – December 2013

In California, a Focus on Getting OTP Patients Enrolled in Medicaid

MediCalOpioid treatment programs (OTPs) have many patients—childless adults, mainly men—who have not been eligible for Medicaid. They are self-paying for their treatment. In these weeks before the Affordable Care Act (ACA) takes effect and self-paying patients can be covered under its Medicaid expansion provision, some OTPs are working feverishly to make sure that these patients are enrolled, and finally freed from the burden of paying out of pocket—something that will improve the chances that they will stay in treatment.

At Bay Area Addiction Research and Treatment (BAART), the focus is on implementing Medicaid expansion, said president Jason Kletter, PhD. BAART is based in California and has expanded into Arizona, North Carolina, Nebraska, and Vermont, serving more than 6,500 patients a day. BAART also provides primary medical care and mental health services through fixed sites and mobile vans.

“My organization has been certified as an enrollment entity, and we have about 30 people at sites around the state ready to enroll patients,” Dr. Kletter said. There have been logistical problems, but “we’ll get there eventually.” As in the rest of the country, technical hiccups in getting started are expected to be worked out well in advance of the January 1 ACA implementation date. “We currently have certified enrollment counselors who can’t do their job yet,” he said. The state’s exchange, Covered California, is managing the enrollment.

Dr. Kletter thinks the main advantage of Medicaid expansion will be to make sure current patients who are paying their own way will have insurance. “It’s a great benefit for these patients, because these are the folks who have a hard time staying in treatment.”

California Medicaid, called Medi-Cal, is still fee-for-service for treatment of substance use disorders (SUDs); many states are applying for federal waivers to put this population and health care providers under managed care. Instead, California went through a “realignment,” in which SUD treatment went from a centralized state management system to payment by the counties. “And they’ve added a lot of benefits to the Medicaid benefit, said Dr. Kletter—residential, intensive outpatient, and other services.

Medicaid money goes through the counties, and OTPs contract with each county, said Dr. Kletter. “After the realignment, I don’t see this being managed” by private insurance companies, he added.

But what about patients who already have commercial insurance—they have traditionally found it impossible to use their insurance to get reimbursed for treatment in an OTP, and they also had to pay out of pocket. That may be changing soon. “There’s been a recent change of heart, and managed care organizations are starting to reach out to OTPs in California,” said Dr. Kletter. The OTPs met with the state last year about this. “We think that the exclusion is discriminatory,” he said, referring to insurance policies that specifically excluded treatment with methadone in an OTP, or any treatment in an OTP. Of course it is discriminatory, under the ACA and the parity law. Any change in this would be a “great development,” Dr. Kletter believes, expanding OTP access not only to many people covered by Medicaid but also to people covered by private insurance.

Site last updated July 17, 2014 @ 5:55 pm