Medicaids Critical Role in Addressing the Opioid Crisis April Grady - - PowerPoint PPT Presentation

Medicaid’s Critical Role in Addressing the Opioid Crisis

April Grady Manatt Health Strategies June 25, 2018 AcademyHealth Annual Research Meeting

A grantee of the Robert Wood Johnson Foundation

With support from:

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About State Health & Value Strategies

State Health and Value Strategies (SHVS) assists states in their efforts to transform health and health care by providing targeted technical assistance to state officials and agencies. The program is a grantee of the Robert Wood Johnson Foundation, led by staff at Princeton University’s Woodrow Wilson School of Public and International Affairs. The program connects states with experts and peers to undertake health care transformation initiatives. By engaging state officials, the program provides lessons learned, highlights successful strategies, and brings together states with experts in the field. Learn more at www.shvs.org.

About Manatt Health

Manatt Health integrates legal and consulting expertise to better serve the complex needs of clients across the healthcare system. Combining legal excellence, first-hand experience in shaping public policy, sophisticated strategy insight, and deep analytic capabilities, we provide uniquely valuable professional services to the full range of health industry players. Our diverse team of more than 160 attorneys and consultants from Manatt, Phelps & Phillips, LLP and its consulting subsidiary, Manatt Health Strategies, LLC, is passionate about helping

• ur clients advance their business interests, fulfill their missions, and lead healthcare into the future. For more

information, visit https://www.manatt.com/Health.

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Objectives

• Provide data on Medicaid’s role in addressing the opioid epidemic
• Review Medicaid tools available with regard to:

–Expanding coverage of substance use disorder (SUD) treatment services –Increasing treatment capacity –Addressing prescriber behavior

For additional information, see A. Grady, P. Boozang, D. Bachrach, A. Striar, and K. McAvey, Medicaid: The Linchpin in State Strategies to Prevent and Address Opioid Use Disorders, State Health & Value Strategies Issue Brief (Mar. 16, 2017), https://www.shvs.org/resource/medicaid- the-linchpin-in-state-strategies-to-prevent-and-address-opioid-use-disorder/.

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Data on Medicaid’s Role in Addressing the Opioid Epidemic

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Medicaid is a Major Source of Treatment Dollars for People with Opioid and Other Substance Use Disorders

• Medicaid covers nearly 40% of adults

with an opioid use disorder (OUD)

• Medicaid spending on comprehensive

health care services for people with an OUD is substantially higher than all

• ther federal funding
• Medicaid is addressing OUD along with

a multitude of co-occurring conditions that, if left untreated, perpetuate the cycle of addiction

• Opioid use disorder is only one of many

substance use disorders that states must address

more on services for people with an OUD prior to expansion ($9.4B) than the entire SAMHSA budget for SUD ($2.9B)

Medicaid spent 3x

• pioid overdose deaths in the

United States in 2016

42,000

• f Medicaid spending for

individuals with OUD is for physical and behavioral health issues that co-occur with substance use disorders

>50%

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Medicaid Spending For Medication-Assisted Treatment (MAT) Has Grown Rapidly

• Medicaid covers a range of SUD

treatment services, such as inpatient detoxification, intensive outpatient, care coordination, and MAT

• Most Medicaid spending for OUD

prescriptions is on buprenorphine

– In 2016, Medicaid paid for 24% of buprenorphine prescriptions; nearly double that amount in some states – In Ohio, nearly 50% of buprenorphine prescriptions were paid by Medicaid

• Medicaid spending on MAT drugs has

more than doubled over the past five years, to nearly $1 billion in 2016

• Growth rates have been highest in states

that expanded Medicaid

MAT pairs medication with psychosocial therapies for people with OUDs

Medicaid Spending on Buprenorphine, Naltrexone, and Naloxone Prescriptions for OUD, by State Expansion Status (in millions)

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State-Level Data Illustrate the Key Role of Medicaid in Addressing OUD

In Ohio, a recent study found that expansion adults with substance use disorders were more likely to report improvement in overall access to care than those without, and those improvements were even more evident for the subgroup of enrollees with an OUD Ohio New Hampshire spent $80 million on Medicaid services for enrollees with OUD in 2017, compared to $5.2 million in

• pioid-specific federal grants

from sources other than Medicaid New Hampshire Among West Virginia’s Medicaid enrollees with an OUD, 75% of Medicaid spending in 2017 ($254 million

• ut of $339 million) was for

physical and behavioral health services other than direct treatment of addiction West Virginia

Data from high-impact states indicate that spending on Medicaid SUD treatment alone for people with an OUD was 6 to 12 times the amount of non-Medicaid federal grant funds available to address the opioid epidemic in 2017

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Expansion Adults Account For a Large Share of Medicaid Enrollees in Need of OUD and Other SUD Treatment

Medicaid eligibility changes that limit or restrict expansion adult coverage would have a significant impact on funding of SUD treatment services

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Even Prior to Expansion, Medicaid OUD Spending Was Substantial

• The largest sources of non-

Medicaid OUD funding in 2017 included:

– $500M: Opioid State Targeted Response to the Opioid Crisis (SAMHSA) – $40.8M: Prevention for States Program (CDC) – $12M: First Responders (SAMHSA) – $4.2M: Pain Management Collaboratory (NIH) – $25M: Targeted Capacity Expansion MAT–Prescription Drug and Opioid Addiction (SAMHSA)

In 2013, Medicaid spent $9.4B in federal and state dollars on comprehensive health care services for 636,000 individuals with an OUD

Medicaid Spending for People with an OUD Compared to Non-Medicaid Federal Grants to States for OUD/SUD Treatment and Prevention (in millions)

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OUD Funding Sources Outside of Medicaid Are Growing But Still Limited

• FY 2018 omnibus appropriations bill enacted in March allocates $3.3

billion of funding for 2018 to combat the opioid epidemic

• Builds on the 21st Century Cures Act that funded the previously-

authorized $500 million per year for 2017 and 2018 in state grants

• The $3.3 billion in funding includes:

–$1.4 billion to SAMHSA for state grant programs –$500 million to the NIH for addiction research –$415 million for the Health Resources and Services Administration to improve access to addiction treatment in rural communities –$350 million to the CDC for opioid overdose prevention, surveillance, and state prescription drug monitoring programs –$500 million to the VA for mental health programs

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Congress and the Administration Are Continuing Efforts to Address the Opioid Crisis

• Congressional action as of early June

– House passed the first of several opioid-related legislative packages that are expected to come to the floor in coming weeks – Within the House and Senate, debate continues regarding Medicare and Medicaid legislative provisions designed to address the epidemic – Less controversial provisions include reducing opioid use for pain management, educational efforts, and measures intended to expand SUD treatment provider supply – More heavily debated issues include the Medicaid IMD exclusion and data-sharing/privacy

• Recent Centers for Medicare & Medicaid Services (CMS) actions

– CMS Roadmap to Address the Opioid Epidemic provides an overview of CMS actions to date and future areas of focus – State Medicaid Director Letter provides guidance to states on funding authorities that may support health information technology efforts to address the epidemic – Informational bulletin for states regarding Medicaid coverage and developing effective strategies for the treatment of infants with Neonatal Abstinence Syndrome (NAS)

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Examples of Tools Available to Medicaid in Addressing the Opioid Epidemic

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Medicaid Programs Are Employing a Range of Strategies to Tackle the Opioid Epidemic

Increasing Capacity to Treat Addressing Opioid Prescribing Behavior Expanding Access to Treatment

• Enhance payment rates for providers meeting best practices in SUD prevention

and treatment

• Require health plans to contract with certain providers, pay providers more for

high-priority services, and provide incentives to plans that meet certain metrics

• Conduct systematic review of existing SUD benefits to identify and address any

gaps around payment, services covered, and utilization management strategies

• Expand intensive care management services, including care plan development,

patient navigation services, and outreach & enrollment into treatment

• Design special plans for individuals with mental illness and SUD
• Enhance provider and workforce education on evidence-based treatment for OUD
• Increase Medicaid’s access to states’ Prescription Drug Monitoring Programs
• Require prior authorization for opioids; institute quantity and renewal limits
• Strengthen utilization review criteria
• Promote use of MAT, and add naloxone to preferred drug lists

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Expanding Access to Treatment

Providers

• Create specific care coordination requirements for individuals at-

risk of or who already have an OUD

• Incentivize use of MAT

Prior Authorization

• Allow prescriptions for all MAT drugs to bypass all service

authorization requests

• Lift prior authorization on other forms of treatment when

identified as appropriate through evidence-based assessment

Continuum of Care

• Draft specific policies on Neonatal Abstinence Syndrome (NAS)

including incentives to provide family-based care outside of the NICU when appropriate

States can pursue various routes to expand access to SUD treatment services

West Virginia’s State Plan Amendment (SPA) for NAS Treatment Services

• State Medicaid programs pay more than

$1 billion annually to care for infants with NAS

• In February 2018 CMS approved West

Virginia’s SPA to provide prospective Medicaid bundled payments for NAS services in non-hospital settings

• These NAS treatment centers provide

treatment for infants with less severe symptoms at nearly a quarter of the cost for the same services in a hospital

• r neonatal ICU
• The centers also provide

pharmaceutical withdrawal management, withdrawal monitoring, care planning, and therapeutic swaddling services

Source: https://nashp.org/wv-medicaid-covers-an-innovative-and-less-costly-treatment-model-for-opioid-affected-infants/

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24 States Have Approved or Pending Waivers of the IMD Exclusion

Without a waiver, federal Medicaid funding is not available for residential treatment facilities with more than 16 beds that are considered “institutions for mental disease”

California Nevada Arizona Utah Idaho Montana Wyoming Maine Vermont* New York North Carolina South Carolina Alabama Nebraska Georgia Mississippi Louisiana Texas Oklahoma Pennsylvania Wisconsin Minnesota North Dakota Ohio South Dakota Kansas Iowa Illinois Tennessee Missouri Delaware New Jersey Connecticut Massachusetts ** Virginia Maryland Rhode Island Hawaii New Hampshire Alaska

West Virginia

Colorado New Mexico Oregon Washington Arkansas Kentucky Washington, DC Iowa Indiana Florida Michigan

Substance Use Disorder (SUD) SUD and MH SUD SUD and MH Approved Pending N/A Add’l Request Pending

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Expanding Capacity to Treat

Providers

• Require managed care organizations (MCOs) to describe strategies

for addressing SUD and the opioid crisis (e.g., related to MAT)

• Encourage MCOs to increase physicians with waivers to provide

MAT via withholds, incentive payments, or plan requirements

• Indirectly build capacity building funding into rates or through

directed payments

Continuum of Care

• Require MCOs to ensure that a sufficient continuum of care is

available to effectively treat SUD individuals, consistent with ASAM criteria and CDC Opioid Prescribing Guidelines

• Increase number of residential providers eligible for Medicaid

funding via IMD waiver

While challenging, states have some options to increase capacity to treat substance use disorders

New York: Integrated SUD and Mental Health License

• State allows licensed or certified
• utpatient providers, including primary

care, mental health, and SUD clinics, to integrate primary care, mental health and/or substance abuse under a single license or certification

• Providers must offer minimum services

including, but not limited to screening, crisis intervention, complex care management and counseling

Baltimore, Maryland: Increasing Mobile MAT Capacity

• Baltimore plans to implement mobile

MAT capacity to bring buprenorphine to hard-to-serve patients who may not seek treatment in the traditional health care system

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Addressing Opioid Prescribing Behavior

Prescribing standards and requirements can help to identify outlier prescribers and high-risk beneficiaries

Prior Authorization

• Require prior authorization for the prescription of more than X mg daily Morphine Equivalent

Doses (MED)

• Expand prior authorization requirements for prescribing beyond X days (regardless of MED)

and for repeat prescriptions, even if small doses

• Exceptions for cancer or terminal illness

Pharmacy Lock-In

• Communicate with members regarding the lock-in determination
• Provide monthly pharmacy lock-in reports
• Evaluate the need for SUD treatment for enrollees who enter the lock-in

Transition for Individuals Receiving Repeat Prescriptions

• Require MCOs to gather and report data on provider prescribing patterns to providers and

state

• For beneficiaries receiving prior authorization for prescriptions of more than X mg daily MED:
• Require a pain management contract, pain management consultation, or certification

from the provider that it is for an acute medical condition

• Require urine drug screening
• Require administration of an opioid risk screening tool
• Require prescribing and dispensing of Naloxone

Prescribing Requirements