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State Medicaid programs are grappling with how to fight the opioid addiction crisis and protect their patients, officials told congressional Medicaid advisers March 2.
They’re finding solutions: better linkage of care between program clinics and doctors’ offices, adding case management into plans, creating incentives for safer prescribing, incorporating holistic health and family support rather than just the substance abuse and promoting evidence-based medically assisted treatment. Witnesses told the Medicaid and CHIP Payment and Access Commission the approach is to treat addiction more like any other chronic condition.
“You don’t kick someone out of a diabetes program because they had two Big Macs over the weekend,” Kelly Murphy, health division program director with the National Governors Association, said.
While state health department officials noted real progress and results from the investment they had put in, they also see a long road ahead, especially on the need for better data.
“Addressing the opioid epidemic requires a multi-pronged strategy,” Vermont Blueprint for Health Executive Director Beth Tanzman said.
The crisis claimed more than 500,000 lives in 2015.
In Vermont, the safety-net insurance program really followed the lead of what medical professionals said they needed.
“We took them at their word,” Tanzman said.
That meant supplying doctors’ offices with more nurses and counseling built into treatment models, as well as ramping up psychiatric and underlying mental-health care at highly specialized opioid treatment clinics which tended to focus more on just medications like methadone to scale down the patient’s physical addiction. Today, there are 55 licensed nurses and counselors offering opioid treatments, dramatically increasing access in the small state, she said.
In turn, the number of wait lists has slimmed, Tanzman added, and the expanded access has yielded dividends.
Medicaid has also shifted its focus on placing the responsibility for coordinating services away from patients, who are often not in their right mind and not capable of organizing their care themselves. Promoting family and community supports and home health has been an integral part of Vermont’s model, placing the use of medically assisted treatment in the proper context. The infrastructure first had to be built.
Virginia also created new, nontraditional billing codes for services like group counseling and encouraged evidence-based prescription of buprenorphine over just methadone through financial incentives. The state also prioritized care coordination, with many health analysts noting the system for substance abuse has traditionally been very fragmented.
“Virginia has never paid for care coordination before, but this crisis is so severe,” Kate Neuhausen, Virginia Medicaid chief medical officer at the state’s Department of Medical Assistance Services, said.
Both states noted they had increased training for providers in dealing with opioid-addicted patients and how to administer medications like Narcan to reverse an overdose and buprenorphine as a medically assisted treatment for opioid addiction.
Virginia’s demonstration waiver, approved in December, will also for the first time bring federal Medicaid funds to patients getting substance-abuse care at Institutions for Mental Disease, previously blocked by a longstanding national exclusion in facilities larger than 16 beds. The IMD exclusion is a remnant of the move to deinstitutionalize mental-health care.
Officials said they were working to better document their efforts and implement stronger methods of qualifying success of the opioid treatments.
There are plenty of other challenges still facing states, like better connecting vulnerable patients before relapse in situations like a jail release.
Data on what’s working will be one way to improve, experts noted.
MACPAC Commissioner Andrea Cohen said evidence-based medically assisted treatment will be a “huge area to explore.” Cohen is vice president of the Office of Transformation at NYC Health + Hospitals.
“We don’t want to just allow it; we want to make it easy to happen and maybe someday want to make it hard for states not to be paying for evidence-based treatment,” she said.
Caseload caps also make doctor shortages more pronounced in treating opioid addiction.
MACPAC commissioners suggested telehealth, and better reimbursements for it, could have a big role to play in building branches out of the epidemic for sick patients, especially in rural areas.
All agreed there will be a long road ahead.
Tanzman said her state doesn’t “feel on top of it at all,” in spite of its best efforts, and would rate its efforts to address the opioid crisis just above average, at a C+.
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