By Alison Knopf
The federal government’s approval of Medicare reimbursement for opioid treatment programs (OTPs) was a huge win for patients and programs. Now, the details need to be worked out: in particular, how the bundled rate will be calculated.
The reimbursement will take effect in January 2020. The federal Centers for Medicare & Medicaid Services (CMS) proposed a methodology in its fee schedule for 2020 (https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/PhysicianFeeSched/PFS-Federal-Regulation-Notices-Items/CMS-1715-P.html), published in the Federal Register in August. The comment period ended September 27. The American Association for the Treatment of Opioid Dependence (AATOD) says that the reimbursement—“if properly developed and executed”—meaning, if rates are high enough— will help provide access to care for seniors.
65th Birthday Will no Longer Mean Self-Pay or Leaving OTP
Before the change allowing Medicare reimbursement passed, just under two years ago, people in OTPs lost their Medicaid or commercial insurance when they reached the age of 65. Instead of becoming Medicare beneficiaries, they had to drop out or self-pay. AATOD had fought for this coverage for more than a decade.
AATOD polled its members and found some concerns coming from Connecticut, Massachusetts, and New York—states that already have Medicaid reimbursement structures far above the proposed Medicare rate. If OTPs had to accept less for Medicare patients who turned 65 than they did for the same patients who were 64, that would make little sense.
Another problem is payment for the full scope of services. While the cost of methadone itself is about $400 a year, depending on several factors, the cost of treatment—which includes comprehensive care—probably is at least $4,000 a year.
Specifically, CMS wants to use the TRICARE rate for Medicare to construct a comprehensive rate. But this wouldn’t work, because TRICARE provides only a “basic floor,” AATOD president Mark W. Parrino, MPA, wrote in his comment to CMS on the proposed fee schedule.
Again, many states have more rigorous standards in terms of counseling requirements and staff credentials than TRICARE or the Substance Abuse and Mental Health Services Administration (SAMHSA), wrote Mr. Parrino.
OTPs Provide Referrals, Special Services, Clinical Support Services
The fee schedule should also take into consideration that OTPs function as “hub sites” in many areas, referring patients to buprenorphine, for example. They also provide a “rich array of clinical support services,” including hepatitis and HIV services. These are supplied on-site by some OTPs, and by referral by others.
The fact that the rates are bundled to include medication and visits is good, but ways need to be found to reimburse OTPs for additional services.
Bottom line: OTPs are the only facilities where patients have access to all three FDA-approved medications for opioid use disorders—methadone, buprenorphine, and naltrexone. Methadone is not offered anywhere else.
In the future, CMS should consider all of the following as possible additions to the fee schedule: telemedicine, mobile vans, and satellite units.
AATOD urges CMS to remove the designation “high risk” from OTPs. “As a point of fact, if any designation needs to be applied, we would suggest that OTPs function in a ‘low risk’ category,” writes Mr. Parrino. “In our judgment, the OTPs do not need any additional certification or oversight.”
Finally, Mr. Parrino notes that the value of reimbursement is to ensure access to care; for Medicare, it is to ensure that the patient can stay in treatment as long as the treatment offers a benefit.