Opioid treatment programs (OTPs) are finally able to bill Medicaid for buprenorphine treatment in New York, Allegra Schorr, president of the Coalition of Medication-Assisted Treatment Providers and Advocates (COMPA, formerly the Committee of Methadone Program Administrators), announced in April.
Under the new rules, OTPs will be reimbursed $7.01 for 8 mg of buprenorphine, using supply code J0592. The maximum reimbursement per patient per week is $196.28—four 8-mg doses per day, for seven days. This is effective immediately, retroactive to January 2015.
All of the buprenorphine medications—branded and generic—are on the Medicaid formulary, as is Vivitrol, said Ms. Schorr. OTPs have the option to pick any formulation they choose. This doesn’t necessarily mean that OTPs will always choose the generics because they are less expensive. “It’s up to the manufacturers to contract with the programs,” she said. OTPs can also have different products on hand, to give patients a choice. “That’s what we do with methadone—we ask if they want the orange or the white,” she said, referring to her West Midtown clinic.
This is a huge change, following four years of virtual inability to bill Medicaid for dispensing buprenorphine in an OTP.
“We’ve been wanting to do this for a very long time,” Ms. Schorr told AT Forum. Four years ago, when the state went to a different billing system, OTPs were no longer able to add any new buprenorphine patients; at the same time, the heroin epidemic flourished. “This is really an issue of access to treatment,” said Ms. Schorr, who is also vice president and owner of West Midtown Medical Group, an OTP in New York City.
The New York Department of Health runs the state’s Medicaid program; it is also the parent agency of the Office of Alcoholism and Substance Abuse Services (OASAS), which supports the OTPs’ desire to be reimbursed for buprenorphine.
Billing by the Unit
“We had a big meeting with the Governor’s Office of the Secretary of Health, and once we got their attention and they were made aware of the problem, they moved very quickly,” she said. “I’m delighted.”
Under the new billing system, buprenorphine is reimbursed the same way methadone is. “We get paid for each visit, and we get paid for the cost of the medication,” she said. The OTP puts in a claim for per-unit dispensed, which is then tagged at a pharmacy rate. “This allows us to claim how many units are dispensed each week. She noted that this covers take-homes. (Unlike methadone, buprenorphine take-homes can start from the first day of treatment.)
The maximum per patient that OTPs can charge per day is 32 mg of buprenorphine, said Ms. Schorr. She added that this is high enough to cover all patients’ needs.
Increasing OTP Patient Capacity
Increasing the capacity of OTPs—currently capped at the discretion of OASAS—is also under consideration by the state, reported Ms. Schorr. “They would consider lifting the limits if we would do scheduled visits for patients, and offer more medications,” she added, citing Vivitrol. (Henry Bartlett headed COMPA until last fall, when he became the Alkermes sales representative for Vivitrol in New York.)
The idea would not be for patients to switch from methadone to Vivitrol or buprenorphine, but for new patients to be offered these medications as an option at entry, said Ms. Schorr. “Current methadone patients need to understand they have to come down on their dose and be completely off medication” before starting either buprenorphine or Vivitrol.
Offering more medications is a “positive step for OTPs,” said Ms. Schorr. “It shows we’re not just stuck in a certain mindset—that we really are addiction treatment centers.”
The purpose of the new rule is to increase access to buprenorphine. Office-based physicians are limited to treating 100 patients with buprenorphine. OTPs have no such cap, but they do have a limit as decided by OASAS. Currently, COMPA and OASAS are discussing whether patients on buprenorphine or Vivitrol can be put in their own category, so that they don’t impinge on the methadone census. Everyone would still be recorded in the census, but the OASAS-set census would be restricted to methadone. This was the original intention when the rules were made back when methadone was the only medication OTPs dispensed.
“That’s the last piece we’re working on,” said Ms. Schorr. Without making that change, there would still be OTPs—especially upstate, but even in New York City—that have waiting lists and cannot expand access, she added.