Moving forward in 2023, with a huge proposed rulemaking change for opioid treatment programs (OTPs) (see https://atforum.com/2022/12/samhsa-proposal-update-methadone-regulations/), AT Forum talked to three executives – Megan Marx, director of integrated care at Oregon Recovery and Treatment Centers in Parker, Oregon; Jason Kletter, Ph.D., president of Baymark Health Services, based in Lewisville, Texas; and Nick Stavros,. CEO of Community Medical Services (CMS), based in Scottsdale, Arizona – about their vision of treatment for opioid use disorder (OUD) in the future.
What should the OTPs of the future look like? We know that the rulemaking notice of proposed rulemaking (NPRM) calls for telehealth inductions, permanent liberalized take-home doses of methadone, and allowing the use of mid-levels in methadone prescribing. These, as Stavros points out, are much needed.
In fact, CMS, known initially for its 24-7 operations (see https://atforum.com/2017/12/24-7-access-otps-arizona-federal-str-funds/), is a big supporter of the extended take-home rules. “The fact that some patients have to come in every day probably makes retention rates worse,” Stavros told AT Forum. “We’re hoping that you see people succeeding at higher rates than they had in the past, because they’re not having to come in every day for 2 years.” (These rules about coming in daily are not CMS rules – in fact, CMS is a low barrier program.)
“We’re also very excited about telemed inductions for methadone,” said Stavros. “We have clinics in rural areas, in Montana, Alaska, North Dakota, some areas where there are no medical providers available,” he said. It’s important to be able to “do intakes on the spot,” he said. So the telemedicine inductions are a change CMS has been pushing for.
Low barrier, comprehensive care
“We have the low threshold easy access model,” said Stavros. “We expect all of our clinics to do same day intakes. We don’t put people on waitlists.” This has brought many patients into the OTP system who weren’t in treatment before.
When CMS goes into a city to open a clinic where clinics already exist, it’s not to take patients away from those clinics. It’s to bring in the patients who are not in treatment at all. “Our population has a lot of unmet needs,” said Stavros. “We’re trying to treat some of the high priority issues, like hepatitis C and HIV. We’ve rolled out Hepatitis C testing and treatment in all of our clinics now. This is a place where OTPs can have a huge impact.”
CMS is not just about 24/7, no wait-list, access to methadone. It’s about comprehensive care, and this is what Stavros sees in the future for OTPs. “Because patients come to the clinic to get their OUD medication, they also get their hepatitis C or HIV treatment. It’s an opportunity for them to be tied to other services.”
CMS also helps patients enroll in Medicaid, in states where it exists for them. “This may be the first time these patients are enrolled in any health care plan,” said Stavros.
Another vision for the future, from Marx, focused on harm reduction. “In some places, OTPs are already considered to be providers of harm reduction services,” she told AT Forum. “Most of us provide condoms, naloxone, and sometimes even fentanyl test strips.”
Marx, who was formerly director of OTP accreditation at the Joint Commission, remembers how controversial it used to be to provide even condoms in treatment programs. Things have changed. “We send our clients in need to the needle exchange programs,” she said. “And we use the counseling tools of motivational interviewing and contingency management, not unlike counselors in full-fledged harm reduction programs, to help our patients reduce or eliminate their use.”
Will OTPs themselves ever offer clean needles and “safe” use sites. “I think we have a long way to go to eliminate the stigma associated with active substance use before that could happen,” said Marx. “In people’s minds, providing clean needles and a safe place to use implies support of active substance use,” she said, adding, “OTPs, and SUD treatment generally, are philosophically built around the idea of helping patients eliminate their active substance use.”
Even in the Part 8 NPRM, as progressive as it is, the new six-point criteria for take-homes encourages providers to consider absence of any active SUD in making determinations, she noted.
So there is a reason why harm reduction programs exist separately from OTPs, even though they may offer some similar services. “I think individuals who actively use substances present to harm reduction programs and OTPs along a continuum,” said Marx. “Some want to stop using substances, some don’t. Some want to reduce their use. Some aren’t sure what they want. We need more harm reduction programs, and we need to work closely with them to make sure individuals can access the services that fit their needs. OTPs aren’t set up to help patients manage their active substance use, but often that’s what ends up happening because there isn’t a harm reduction program available in the community to provide those services. And harm reduction programs need to be able to provide a full range of services, including needle exchange, provision of clean, safe use equipment and safe use sites, and can successfully refer clients to treatment programs when someone wants/is ready for those services.”
‘Finding ways to expand’
Baymark, the treatment provider represented by Kletter, is part of “Advocates for Opioid Addiction Treatment,” and Kletter spoke to AT Forum on behalf of both. “The overarching goald for OTPs has to be finding ways to expand,” he said. And this will mean getting Medicaid and other public funders to support it, the way they support other kinds of medical treatment.
“Most of the growth in OTPs in the last 10, 20, 30 years has been private investment, with little to no public investment. Whereas the federal government and the states have been investing in getting private doctors prescribing, there has been little done to make sure Medicaid pays for OTPs.”
States, with a few exceptions, have been “heavy handed in imposing lots of regulations and administrative burdens” that force OTPs to put disproportionate resources to managing a chart, instead of managing a patient, noted Kletter.
Sea change: Insurance
The last few years show signs of hope, said Kletter. “There has been a sea change, starting with Medicare creating coverage for OTPs (something AATOD fought hard for – see https://atforum.com/2019/10/cms-proposes-rates-for-medicare-reimbursement-for-otps/). This meant that OTP patients, upon turning 65 and losing their Medicaid, getting Medicare instead, would not risk losing coverage for treatment. Kletter called this a “landmark moment.”
The result of the Medicare coverage decision was that commercial plans started to pay more attention to reimbursing OTPs, said Kletter. “They didn’t necessarily adopt a full bundled rate, but came up with a more sophisticated model.” Now a number of states are moving towards adopting coverage, especially Medicare Advantage plans (which are actually commercial plans). “We’re trying to educate the Center for Medicare and Medicaid Services and Advantage plans about how those reimbursement plans should work,” said Kletter.
One of the problems for OTPs is that bundled rate (see https://atforum.com/2019/04/cms-samhsa-visit-otps-bundled-rate/). When take-home flexibility increased, it means that payers thought they only needed to pay for the days a patient came into the clinic to pick up medication, and stopped paying for the other days, even though these less-than-stable patients getting increased take-homes still needed monitoring and treatment. The reason for the increased take-homes was avoiding spreading COVID-19, not saving money or increasing convenience. Now, with the Part 8 NPRM, these changes are likely to be permanent, and it means that OTPs need to be even more vigilant about reimbursement.
Part 8 NPRM and the states
Kletter had nothing but praise for the Part 8 NPRM. “Mark [Parrino’s] work with the DEA and clarification on mobile units took a long time, but now it’s there,” he said. “Telehealth inductions, midlevels, and take-home flexibilities all add up to a revolutionary time in our field, so that we will have more tools at our disposal to insure timely access for anyone who shows up” for care. “We have this tremendous opportunity, and we applaud SAMHSA’s work in this regard.”
The big problem is going to be getting states to align with whatever SAMHSA changes bout the rules, said Kletter. As it is, many states did not even give out as many take-homes as SAMHSA allowed, with even Massachusetts, where providers boasted about their OUD treatment, only allowing two weeks until recently, even though SAMHSA allowed four.
“SAMHSA said there’s nothing they can do to pre-empt states regulations,” said Kletter, citing the federal government’s oft-proclaimed loyalty to “state’s rights.”
Instead, there should be open dialogue, among SAMHSA, the National Association of State Alcohol and Drug Abuse Directors, and treatment providers around “the value of state regulations that do nothing but create additional barriers to care.” What are the costs of these policies?
“We say OTPs are an excellent model that combines evidence-based care and consumer and public safety,” said Kletter. “So why are states not significantly investing in expansion of OTPs?”
New day ahead
“There’s a new day ahead,” said Kletter, who could be seen at AATOD this fall actively working on his faith in the system with various important stakeholders, in hotel lobbies and outside conference rooms. This is what is needed. “We need to keep going,” he said. “We are seeing substantial improvements in regulatory and funding mechanisms that will benefit patients all over the country,” he said. “It’s the persistence of these groups, AOAT, AATOD, NABH, that have been insistent in making the case in why we need better access and better funding.”
For 20 years, SAMHSA has been trying to get physicians to get a waiver to prescribe buprenorphine for OUD, and over that same 20 years, overdose rates have risen to tragic, record levels, Kletter noted.
Instead of trying to twist the arms of doctors who don’t want to treat OUD, why not nurture the people who do want to do it?