With opioid overdoses at the highest level ever and still going up – more than 100,000 a year – this is not the time for opioid treatment programs (OTPs) to be losing ground. Yet this is what is happening, according to the Coalition of Medication-Assisted Treatment Providers and Advocates (COMPA), testifying February 14 at a New York State legislative hearing.
The testimony outlines problems and solutions for the states OTPs.
Several of the problems can be helped with money, and this isn’t a bad time to ask for it, as the state budget is flush from a federal outpouring.
- Workforce: COMPA is requesting a $500 million investment to support retention and recruitment initiatives, which includes a Medicaid rate increase, as well as loan forgiveness for education, internship stipends, fellowships in addiction medicine, and a 5.4% increase in the COLA.
- OMIG audits: The entire OTP system is threatened with destabilization under compliance audits conducted by the Office of the Medicaid Inspector General (OMIG). The disallowances have resulted in the loss of treatment slots, and will continue to do so if changes to the audit process aren’t made (for more on the OMIG audits, see https://onlinelibrary.wiley.com/doi/full/10.1002/adaw.32901). “Due to the number of medication visits in OTP treatment, the extrapolation methodology utilized by the OMIG results in exorbitant disallowances such that an audit with a total finding of $407 in claims results in a disallowance of over $7 million, with the loss of one program location and disruption of services to 1500 patients.” Such closures would be prevented by legislation proposed by Senator Pete Harckham (S.4486-A) and Assemblyman Richard N. Gottfried (A.7889).
Expansion of access
Other measures which are needed include expanding access to methadone treatment, via the following:
- Development of mobile methadone units/satellite clinics: Mobile methadone, using vans, is approved by the Drug Enforcement Administration and supported by COMPA. Increased access to treatment using satellite clinics is also approved by the DEA and supported by COMPA. Vans and satellite clinics operate in conjunction with brick-and-mortar OTPs under federal regulations (for more, see https://atforum.com/2021/09/methadone-vehicles-otps-experience/).
- Expanding access to methadone delivery: Patients who are physically unable to get their methadone, such as those in nursing homes, should be able to get their methadone delivered to them.
The combined license
The Office of Addiction Services and Supports (OASAS) should be able to issue a combined Part 822 license, which would enable outpatient substance use disorder (SUD) treatment programs (known as OASAS Chemical Dependence, programs) to apply for federal OTP licensure, according to COMPA. Combining the SUD and OTP licenses would allow OTPs to provide comprehensive outpatient care to family members, and would increase methadone capacity and access.
The biggest barrier to this expansion now is the disparity between reimbursement rates for SUD outpatient programs and OTPs, with outpatient SUD treatment providers paid more than OTPs for the same services.
To illustrate this disparity: In downstate New York, OTPs and SUD treatment providers receive these rates:
| SUD | OTP | |
| Individual therapy | $109.00 | $100.43 |
| Brief treatment | $49.23 | $45.36 |
| Group therapy | $56.33 | $51.90 |
| Med. mgmt. OUD | $122.00 | $112.40 |
| Med mgmt. cocaine | $140.11 | $129.08 |
| Med mgmt. AUD | $145.41 | $133.97 |
Other needed changes
Toxicology add-on code for fentanyl: There should be a toxicology add-on test code for fentanyl for OTPs, according to COMPA. OTPs have one overall reimbursement rate for toxicology testing, but testing for fentanyl is more expensive than for other drugs. In the current OTP reimbursement structure, testing for fentanyl is “cost-prohibitive,” according to COMPA. “Where OTPs have performed random fentanyl testing, they report a high prevalence of fentanyl among OTP patients,” according to the testimony. “It is imperative that this is rectified quickly to ensure that patients receive appropriate care.”
Integrative services with mental disorders: Proposed legislation by Senator Harckham (S.6311) and Assemblywoman Chantel Jackson (A.8099) authorizes the state health department to establish a set of standards and requirements for comprehensive outpatient services centers for both mental illness and substance use disorders. These centers would make it possible for patients to access services easily for co-occurring mental and substance use disorders.
Parity with physical visits for HCV: More than 80% of OTP patients have hepatitis C (HCV). OTPs are uniquely positioned to identify and treat these patients, but reimbursement for physical health visits in OTPs is substantially lower than it is for a single visit in a primary care clinic. COMPA would like to see the OTP reimbursement for treating HCV to be adjusted to a sustainable rate.
Going beyond the criminal justice system for referrals
Because many neighborhoods are observing increases in homelessness, active drug use, and crime, there are frequent calls for policing, but the most effective response is to increase social services and outreach for services, according to COMPA. New, harm-reduction, social service and healthcare collaborations are effective and human, and treatment for addiction is now mandated by many drug courts and probation and parole departments. In fact, many OASAS providers receive and depend on patient referrals from the criminal justice system, COMPA noted. “It is necessary to develop and provide alternative referral sources, such as the MATTERS (https://mattersnetwork.org/) Program, so that OASAS providers are less dependent on referrals for criminal justice,” according to the testimony.
For this to happen, and for OTPs to gain acceptance from the criminal justice system, a stronger referral system is needed. Here are some specific recommendations.
- Overdose prevention sites: The Safer Consumption Services Act (S603/A224, from Senator Rivera and Assemblyman Rosenthal) is supported by COMPA as a part of harm reduction
- Outreach teams: COMPA supports these as liaisons among harm reduction, mental health, medication assisted treatment, and housing providers.
- MAT in correctional facilities: It’s important to ensure that all “alternative to incarceration” programs utilize referrals to medication-assisted treatment.
Insurance
Finally, there is the importance of reimbursement, so that patients’ treatment is covered. Access to OTP services is covered by New York’s essential health plan and Child Health Plus, but there is no mechanism for billing. “This makes it impossible for OTPs to provide services to people and young adults under these plans,” COMPA notes, adding, “These patients deserve the same access as everyone else to MAT and OTP services, and this should be corrected in the upcoming state budget.”
Network adequacy and access to commercial insurance networks is also important, to ensure that all OTPs and DATA 2000 (buprenorphine office-based) providers can participate in the state’s managed care networks, and this should include an “any willing provider” clause for health insurance plans.
Stay tuned to see how the state’s budget turns out for OTPs and patients.